The Doctors’ Lounge
Where scalpels meet systems — and physicians say what they really think.
Co-hosted by Anish Koka, MD & Anthony DiGiorgio, DO. Candid talks on healthcare policy, reform, physician autonomy & patient care.
The Doctors’ Lounge
Free Markets, Private Equity, and the Moral Case for Medicine
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Episode Summary
Jared Rhoads, founder of the Center for Modern Health and senior lecturer in health policy at the Dartmouth Institute, joins Drs. Koka and DiGiorgio for a wide-ranging conversation on the philosophical foundations of healthcare policy. Rhoads — an Objectivist in the tradition of Ayn Rand — argues that physicians have a right to pursue health, not a right to be given it, and walks through what that distinction means for real policy debates: FDA drug approval, prior authorization, the ban on physician-owned hospitals, private equity in medicine, and foreign-trained physician licensure. The episode is a rare attempt to make the moral case for free markets in medicine, not just the efficiency case.
Chapter Markers
00:00 Introduction and guest background
01:52 What is the Center for Modern Health?
04:25 Objectivism, Ayn Rand, and rational self-interest
11:19 Healthcare as a private good vs. community good
13:58 Policy mistakes made for edge cases
16:58 You have a right to pursue health — not to be given it
20:14 Does Medicare violate rights?
22:47 Positive vs. negative rights in healthcare
24:47 The FDA, drug approval, and the Prasad/McCary departures
31:08 A two-tier FDA review proposal: private vs. public payers
42:25 Breaking up Big Medicine — the Hawley-Warren bill
49:43 Prior authorization: structural problem or reform target?
55:22 High-deductible plans and why price consciousness hasn't taken hold
57:43 Price transparency laws: do they actually work?
01:02:49 Section 6001 and the de facto ban on physician-owned hospitals
01:06:04 Stark Law, Medicare Advantage, and a possible reform path
01:11:19 Private equity in medicine: where are the actual rights violations?
01:19:02 Free markets and monopolies: the standard objection answered
01:21:12 Foreign-trained physician licensure
01:34:11 Immigration, physician workforce, and the battle of ideas
01:37:40 Center for Modern Health summer fellowship
Co-Host Handles
@anish_koka and @drdigiorgio
Show Handle
@drsloungepod
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SPEAKER_00This is the Doctor's Lounge. Hello and welcome to this episode of the Doctor's Lounge. Today, uh May 14th, we are lucky to have Jared Rhodes. Jared Rhodes is the founder and executive director of the Center for Modern Health. This is an independent health policy institute he launched in 2024 that's basically trying to do something that nobody on the right or the libertarian side of health policy has been willing to do anymore, which is make the moral case for free markets in medicine, not just the efficiency case. He's also a senior lecturer in health policy at the Dartmouth Institute for Health Policy and Clinical Practice, where he teaches in the MPH program. He's a senior affiliated scholar at the Mercatus Center, George Mason, and an affiliated scholar with the Foundation for Economics Education. He has an MPH from Dartmouth, an MS from Bentley, and before academia, he spent close to a decade in healthcare consulting. Jared has been one of the most prolific independent voices on state level health policy reform, direct primary care, right to shop, licensure reform at the healthcare openness and access project. We could go on and on. He's testified in Vermont this year on the Foreign Train Physician Licensure Bill. He contributes to medical economics frequently. And he's published a paper most recently on a closer looks at um uh private equity in healthcare. He actually argues that uh the conventional anti-PE narrative in medicine is is overcooked and that most of the standard complaints don't really merit merit much. So we're gonna talk about all of that because you know these are things that physicians are constantly talking about. So Jared, thank you so much for coming on and welcome to uh the doctor's lounge.
SPEAKER_03Well, thank you very much for having me. It's uh I'm sure it'll be a fun uh hour or however long we go. Yeah.
SPEAKER_00Thank you. Absolutely. So tell me tell me a little bit about yourself. Tell me about uh this uh Center for Modern Health and uh uh why you decided to found it or uh how that came to be.
SPEAKER_03Sure. Yeah. So Center for Modern Health uh started a couple years ago, and um I always kind of knew I wanted to be in the in and around the the think tank world. Um I sort of have uh you know a foot in the think tank world and a foot in in the academia world because I I like both. And I for a long time I couldn't decide what I what I wanted to wanted to do. So I was doing always dabbling in a little bit of both. What I like about uh the think tank world is you've you know you've got a little bit more of a direct channel to possibly making something actually happen. It's I mean it's great to study something ad nauseum at you know suit in a in a super you know narrow sense the way they do in academia, but uh that doesn't always lead to and you you know you might get a great idea from that, but that doesn't always lead to any kind of actionable change. You know, I was a little bit more you know hopeful to to actually bring about some change. And so that's uh kind of why I went the the the route of um getting more involved in the uh in the the think take world. Fascinating.
SPEAKER_01The I'm smirking from the academia side over here.
SPEAKER_03I mean, obviously well uh okay, so there's present company excluded. Maybe so like when you're talking about clinical stuff, like you're running a uh a trial or something that really does change the the thinking on you know like what to prescribe or what surgery is better. Like that that actually that changes the world more frequently, I would say. But you know, if you're a policy person like me, you're you're often just writing policy papers and and studying s the percentage of of you know measuring something down to the nth um uh decimal point for you know for what. And so yeah, that that's that's what that's what I would add on to that.
SPEAKER_01No, I I love the perspective. We uh we like to write papers over here on this side.
SPEAKER_00So you wrote a um, you know, you wrote just in terms of what the in intellectual kind of underpinnings are and like where you come from. You wrote um you wrote about the the the right to healthcare that we do have. And uh you you cite um a favorite of some of our listeners, uh Ayn Rand. Yeah, that's right. So yeah, can you can you elaborate a little bit more about are you are you uh a Rand objectivist? I would say so.
SPEAKER_03Now, I mean I I I'm I'm not like terribly active and I guess like the movement or anything like that, but um but yeah, no, I I I take a lot from her kind of foundations and everything. I think a lot of that is is also how you implement it too. And and the certainly the thing that I would emphasize on that is is reading her closely, taking it seriously, trying to implement it the way I think she intended it, which would be a very sort of long-term, enlightened view of selfishness is the is the idea, the is the key ethical component to that philosophy, right? So I'm sure a lot of people know that who are listening to this. But uh there's a there's a big difference between taking that in a in a thoughtful, long-term, rational, enlightened kind of way versus uh kind of caricaturizing it and uh making it, oh, so you're you're for uh just like walking over people and and stuff. No, not at all. Um and and so I uh in in a more enlightened way, I uh do draw a lot from from that.
SPEAKER_00Right. And I think it's worth it's worth fleshing out because too often the crete critique of Rand uh gets lost in this kind of straw man, right? That's created. Yeah. So, you know, objectivism as a as a philosophy, it relies on this idea that the best system for all, and correct me, you know, obviously schooled more in this than I am, but from what I gather, it's this idea that rational self-interest and selfishness should not be something that should be you should not run away from it. Uh actually running towards it is what actually creates kind of uh a better society for all.
SPEAKER_03Right. Yeah. Yeah. And and so in the question of like ethics, you know, like a core question would be, should you primarily live for yourself or should you primarily live for others? And and if you take if you take the latter seriously, well, then what are you doing? Are you are you going around kind of like sacrificing yourself to to others constantly? What does that ultimately look like? That doesn't seem to be, you know, you're living the life that somebody else is asking you to live, or you're just you're seeking out, you know, people to to to like sacrifice your life to. Uh you know, where does that really lead you? A different view is to think about, okay, what values do you have and how do you want to pursue them? And I think, and again, like as long as you're you're thinking about that in a in a thoughtful um and kind of you know long-term and in an enlightened, enlightened way, I you know, I think that's a better uh path forward.
SPEAKER_00Yeah, it's always been fascinating to me because she is to the right of most libertarians in the sense that she rejects any state function that doesn't involve protecting private property or you know the military. But but how do we what is the ethical framework that you think kind of underpins that? You know, it seems like and her story is of course super interesting, right? She partly her her worldview is formed by the fact that she comes from the Soviet Union, right? She's a she's a Russian Jew that emigrated to the United States, and uh her pharmacist, pharmacy business was basically destroyed by the by the state. And so she's just virulently opposed to any state functions that that kind of impede on personal business, you know, private enterprise at all. But can you can you g give us a sense of can you can you clarify like how do you arrive at taking care of your your fellow man who doesn't have, you know, who the truly disabled or the truly indigent? How does how does how do how would she approach that? And how do how do you and and how do you approach that? Is there any daylight between what she thinks and you think in terms of that?
SPEAKER_03Yeah, yeah. Um, well, I mean, I I think she would see something like, okay, the you talked about the the indigent, the people who like truly can't help themselves. That that is something where there's a role for charity. She she wouldn't, she would definitely wouldn't put that as like a primary in life. I mean, I suppose she would say if you want to make that as a profession, like if you care about that population, that particular disease or condition or et cetera, and you and you want to take that on seriously and work with those people, for instance, like that could be a productive part of like a profession. But like as a as a society, the primary orientation should be to sort of produce and achieve as much as we can so that we can have and to a certain extent help others and and that it's not a that much of a drain on on people. If you can, if you first and foremost produce a lot of wealth, for instance, then you're in a better position to make things better for everybody. And so, so being generous, being kind, etc., that's uh that's that's very much part of a a life well lived. Absolutely. It wouldn't be she would consider it a moral inversion for that to be for it to be, for instance, like you you can't live for yourself until you, you know, um handle this this need, right? So she would say produce first, and then with what you've produced as you see fit, you're certainly free to to to help others as you as you want. And others are going to be of value too. You know, your family's a value to you, your neighbors are of value to you in different, different, you know, hierarchies and in different um uh calculations and magnitudes. You know, and that is so that is part of your life. And so, you know, you know, don't be the again, the the the the character here would be the or the straw man would be the that um you just I don't know, go off and uh make a lot of money and then like you know retreat as a hermit on some mountaintop or something like that and and and don't deal with people, right?
SPEAKER_01That's that that's not uh would not be the her real philosophy. I think I found the uh the economic framing of goods to be really helpful in thinking about these sort of things, you know, private goods versus community goods versus public goods. And really, healthcare for the most part is a private good. It is both rivalrous and excludable. But in some cases, it it sort of does fall into more of a community good, especially things like trauma care, acute coronary syndrome, this sort of stuff where you walk into an ER. And in my thinking, almost like some of that should be funded, like the way we fund firefighters, right? Where really fire protection is kind of a community good, a police protection as well. So where would Rand sort of fit on that spectrum? Because I the way I see it most efficiently working is a small community comes together and says we're gonna fund this as a group and then and then provide this group to the community. Is that kind of in line with her thinking?
SPEAKER_03Um well, I I mean, she was against uh taxation. So if you're if you're saying, well, it would be like you know, funded through like um coercive taxation, she would oppose that. And so that that might cut off that that op that option there. Uh although you could absolutely raise the f weren't the first um fire departments um like privately funded. They're private.
SPEAKER_01Yeah. But then you run into the free rider problem, right? Right. Yeah.
SPEAKER_03Yeah. So they're yeah. And we start to get into edge cases like that too. One thing I I try not to do is is let like uh an edge case like that or a tough situation like that thwart or or um or send us down the wrong path for the 95% of the other system of the rest of the system and and make that work worse, right? And actually sometimes we see that in policy. Uh, you know, somebody is concerned about uh to take the uh like the physician known hospital example, right? Like some somebody's concerned that um there might be some overuse and self-referrals that are, you know, sorry, and so what do they do? They they actually they design the system to to in institute a massive ban, which is a very blunt response to what might be a fairly small problem that could probably be dealt with in some other way, right? That's that's the I mean I I sort of try not to, like I said, uh, you know, worry about like the small piece there and and redesign the the the rest of uh uh uh society first to to first deal with that. You know, either let's let's first deal with the the the 80 and then worry about the 20, you know, the 80, 20 uh split classically.
SPEAKER_01And I think unfortunately that's how most people have a healthcare policy debate, especially if you start talking about shopping around for healthcare, people immediately counter with the line that well, you can't shop while you're having a heart attack. It's like, of course you can't, but 99% of healthcare transactions are not you having a heart attack. They're x-rays and labs and primary care visits.
SPEAKER_03That's a that's a great example, right, in the shoppability space there, you know. Like how, you know, how many problems are there where having more money in the hands of the patients and being able to direct that and and and and letting letting more of the cost consciousness decision happen between the patient and the physician, let's say, and not have a need for the insurance. I mean, we I'm I'm not anti-insurance. I think there's a role for it, of course. But if if more of that can be done, for instance, between the patient and the and the physician, and then that sort of obviates the need for worries about other downstream uh problems that might arise.
SPEAKER_00That's such a great point in terms of why everything is getting worse because we're constantly organizing around like that one tragic case. But that seems to be how we make policy. There's like one resident that fell asleep. We don't know anything about the resident or the intro the trainee in medicine that fell asleep somewhere and there was an accident or something. It is tragic and terrible. Someone launches a campaign and and and literally the entire training of medical residents is now changed because of because of that kind of edge case. And yeah, it it really does feel like we have to have like a reset in terms of understanding what our shared expectations are, you know, because so much is just granted as a given. And I'm like, wait, that's not a given. Like healthcare's a right. Wait, wait, all this, you know, and as a as a medical student, resident fellow, et cetera, you just don't spend any time thinking about this. Like this is not part of what is in medical school, in medical schools taught in medical schools or even at an undergraduate level, especially for a lot of the gunner type future doctors, right, who are like focused on like memorizing 10,000 pieces of anatomy and doing super well so that you can ultimately take off somebody's that you can successfully take off somebody's bone from their skull and put it back in. I mean, you know, amazing stuff that that uh physicians do that requires a lot of technical skills. But we're completely unprepared for this whole discussion of it should is healthcare right? And what exactly does that mean? Because we're so it's so inborn within most of us to just reflexively say, of course healthcare is a right. We don't actually think about where that can't comes from, right? This idea about and so what you've talked about, right, that rights derive from the nature of man and the subjectivist philosophical frame.
SPEAKER_03So I'll say a little bit more. And so in that piece, the I I do kind of take a little bit of a sort of a clever, maybe just some clever titling. What I'm trying to actually catch people's eye with, because they they maybe they've maybe they know that I'm about to say that that healthcare isn't a right. But what I what I say is, well, healthcare is a right, but not in the way you think. And and what I what I say is you have a right to pursue health. And that's actually pretty, pretty core to our like the Center for Modern Health, like the you know, the if you read our about page and stuff like it, it that that kind of message is is on there. But we view health as this thing that you ought to be able to like joyously pursue. Like how many of us are are actually sort of kind of dread having to deal with the healthcare system because of like the opaque pricing and you don't know where to go and what to do, and you're getting shuffled around and it's and you feel like you have no control. There it's it's not a very, as it is today, it's not a very joyful experience to be a patient and to like pursue your health in the healthcare system. And but we we think it should, we think it should be something that is is better and a better experience. And so we we'll we'll say, look, you know, health is this, is this thing that you uh it's a value that you ought to be able to pursue in a positive way. There's just the way that you you pursue other values in your life. And and that's the right that you actually have. So there, and there are ways in which that right are that right is um is violated in today's current system, right? Like if if you want to see this doctor and pay in this way, you might not be able to do that depending on the the circumstances. You um, you know, you you you can't well now you can because there's sort of like right to try, but you know, for for a long time you couldn't take an experimental or an investigational drug until it's approved by the FDA, right? So there's an issue there. Uh the lots and lots of ways in which our right to kind of pursue health the way we want to is not respected. And so that's in that piece I'm saying, yeah, you do have a right to health, it's it's uh it's to pursue it, not not to be given it or it's to be granted on you. And you know, healthcare isn't something that's done to you or given to you. It's something that we like to think of it as something that people pursue critically in coordination with with producers, too. If you know anything about uh objectivism, for instance, you know, you'll know that the role of the producer is is really key to her philosophy, right? Um, you know, uh very very much celebrating the the people who are creating the amazing services and goods and medicines and treatments and therapies and everything, right?
SPEAKER_00That's like really Yeah, absolutely. John Galt, fostering and nurturing John Galt. So go ahead, Anthony.
SPEAKER_01Does Medicare therefore violate our rights? I mean, if you really want to take that to the next step, right? So as a Medicare participating provider, I cannot give a cash price to a Medicare beneficiary. So therefore, they don't have a right to pursue health in a way that they would like using their own resources. So does Medicare in itself violate rights? Absolutely say it does, yes. And I I think that's a great example right there.
SPEAKER_03Yeah. We're also at the Center of Modern Health, we're always trying to analyze problems that in a way that's going to be helpful too. And so some of our writing, some of our commentaries are uh a little bit more philosoph philosophical and and sort of talk about the culture of medicine or the culture of the healthcare system and the and the policies we we have in place. And other times we will dive in with a very specific weighing in on you know whether some particular bill or change is a good idea or not. And in the latter case, for instance, sometimes we have to grant that something exists, right? And so, like, you know, off the right away, I'm not gonna say, oh, Medicare, you just gave me an example of Medicare violating rights, therefore abolish Medicare tomorrow. Like we that's not that's not feasible right now. There's not way outside the Overton window, et cetera. In a different piece, we might take a step back and say, look, this is this is a problem. And if we want to, in a long term, more of a um uh much longer term, maybe we can move the system it toward a system where we don't need it, or where there's a really clear cleaving and a split between the public systems and private systems, and we let a private system exist that's unencumbered by rules that the public system has. Even that would be a bet, that would be an improvement, I would say, on the status quo if we could just have more of a like a firewall between some of these things, right? Because, like you said, there are some Medicare rules that bleed into how it affect how what and limit what you can do in the private world, right? And we all know that like Medicare prices, they set, they set you know fake prices, prices with uh square scare quotes around them. They're really just negotiated dollar numbers. They're not, they don't even deserve the word price because it's not a market-deriven price. And and and then that's that becomes like the standard that everybody in the private world just sort of like defaults to, and that's frustrating, right? And and so there I think there's too much bleed between the two. It'd be it would be at least a step in the right direction if we could separate the two a little bit.
SPEAKER_00It's an important i it's such an interesting uh uh discussion uh in in part because uh i you know, the that that that paper you wrote, uh the essay you wrote about the right to healthcare uh that we do have. Um, you know, you talk about positive and negative rights. Uh you know, th there's no positive right to healthcare in the sense that most people think about. And you know, I think in order to have the conversation, I mean, this is not something that anyone is even most people, I should say, are not are not really broaching. But uh, you know, because we've come to accept this, you know, there's a guaranteed enforceable entitlement to medical care that's financed collectively through the state. That's just that I mean that for most people in medicine right now, Jared, uh Jared, um that's just how it should be. And that is like written in the Ten Commandments. But you're of course outlining uh this a negative right to pursue health. Uh so you know, it's a right not to be prevented from seeking out kind of the care you want. And I think that's kind of a um uh yeah, a nice way of discussing it because y you're not really leaning into this old, you know, because it's easy to straw man objectivism, self, you know, self-rational self-interest and you know, uh people are dying on the street or whatnot. But the idea that the system that we currently have is actively involved in preventing you from pursuing the health that you the healthcare that you need. And and there's a number of ways you've already outlined it. There's the physician ban on hospitals, and yeah, in a nice segue, this FDA paternalism when it comes to uh access to investigational treatments. Have you been following anything that I've been prattling on about when it comes to Marty McCary and uh uh Vinay Prasad when it comes to the FDA? Um we're gonna we're gonna test we're gonna test this uh test this in in uh you know in i in the real world in terms of and ask you some questions.
SPEAKER_03So no, not really. I now I I do recall.
SPEAKER_00He has me on mute, see? Uh which is what most of my followers do.
SPEAKER_03No, I do recall that you you wrote like a uh a long piece uh right what what what was it? Right when it was it when Vinai joined or no the the first time that he kept getting fired, so every time he got fired, I would write something.
SPEAKER_00Yeah. I was like, what the heck? So so okay, so this all sounds great, right, in uh in in principle, and I'm like, uh you know, we're right there. But so now we have the system set up, Jared, which which is the FDA. And the FDA by again, because of some came to be in the in its current form because of the Keyfaver Harris amendments that exist now to not only protect the public from bad goods that could hurt them, which is what the original FDA was supposed to do, but now it was supposed it is now supposed to brand every therapeutic that someone wants to foist on the American public. It the FDA is to brand it with does it work or not? And if it is non-working, the FDA says no, this is not a working product, this is snake oil, then the American people do not have access to that. So sounds like a okay, fine, the system that you know I would have bought into or and a lot of people do buy into. And it of course results in it's essentially controlling access to the most voluptuous market in the in the world. And so there's a tremendous amount, as you can imagine, tremendous amount of gaming. That system that's attempted to happen. You know, the gaming takes the form of designing trials to show efficacy. The gaming takes the form of blatant, you know, even if the trial is done and the FDA reviews it and says this is not working, there's a coalition of biotech, biotech investors, plus rare disease community members that feel like, oh my God, I have a rare disease that infrequently is terrible, some of these terrible diseases. And there's a massive campaign to say, hey, we need to get this, I need access to this drug. And this coalition kind of forms to push it. And in my opinion, the last eight to ten months, Marty McCary and Veneversad have both been both essentially exited the FDA. Not in small part because this coalition essentially was upset about decisions that were made by this FDA about efficacy or not. About about the fact that these drugs didn't work. I, you know, dove deep multiple times to look at the actual primary data on some of these drugs. One of these for Hunting's disease, where it requires like delivering uh a um genetic therapy into deep into the brain. It's like an eight-hour surgery, and the data looks horrendous. It looks terrible.
SPEAKER_01For a normal surgeon, maybe.
SPEAKER_00Right. For a normal surgeon, right? For Dr. DeGiorgio, who's basically half robot, he can do it in half half an hour. Yeah. In my sleep. Right. But but anyway, there's all this gaming that happens, and I I've I've I've delved deep into it. I'm not going to waste the people's time. Uh, you know, we've had whole episodes on this on this thing. But anyway, it in my in my my short my summary, my too long don't read version is is that the data is horrendously bad in terms of suggesting that this works. And no, if the FDA is saying, should this does this work or not? Well, you know, you have not shown that this works. And now there's this massive coalition that gets very upset, and and now Marty McCary and Vanette Personer are both gone from the FDA. What's your comment on how things are working and how how would Jar the Jared Rhodes, the objectivist, approach this? What's your perfect system?
SPEAKER_03Well, as so okay, this is actually it's funny that that that that we we touch on this. I've got a draft of a of an article that's uh that might come. I don't know how you know how how soon after we finish this that you publish the podcast, but it might even be out by the time uh our listeners uh hear this. I've got a draft of an article that I I wrote or started sketching out in uh November of last year. And it comes, it looks at this issue where um okay, the FDA, it's on the one hand, you know, classic kind of public choice incentives in place, right? Like you've got they they've got every incentive in the world to be cautious and and to to to not have things approved that then go on to be dangerous, have a have a bad side effect, et cetera. And so there's there's that dynamic in play. On the other hand, you know, part of me is like, well, people should, you know, we shouldn't have the why are we having a government bear uh bureaucrat decide what uh you know what drug to people can take, right? So as as sort of like rough sketches of the starting point, that's that's uh that's where we sort of start. But this piece that I was working on and might even be out, like I said, um by the time we we we publish. I've started to come around to the thought that that what if, and this is so a little experimental uh idea here, but what if we have a system where you're allowed to bring the drug to market, but by market, what we're talking about is a private market. So we turn the dial of review way down on things that are going to be bought and paid for by private insurances and so on and so forth. But we keep andor maybe even increase the uh the the dial on um on of review on things that are going into the that that are going to be paid for by a public uh pair. The thing that I had in mind is is exactly what I think Venight Persad was dealing with at the time. Wasn't one of them like a Duchesne muscular dystrophy? Yeah, like there was a Serepta, I think was that the one that and and it was like a Don't get a niche started. Okay, well, I I mean I'm waiting into this carefully because I I I I don't I forget what your exact position was, but like right. So there you had a a super expensive drug. Uh, it was you know, three million dollars for it's a gene therapy, so it's like a one-time thing, but it's it's supposed to work after the first. But um I at least as I recall, uh you guys are the doctors, you can correct me on this, but I I did take a look, uh a quick look at the um at the original paper on that. And I remember thinking, well, that's a pretty minor improvement, right? And and I and because it wasn't like the the I think the improvement was something like um the the the outcome was like the time that it took you to like walk 10 meters or something like that, and and it improved by a couple seconds. And I'm thinking to myself, three million dollars to like get across the room a little bit quick more quickly. Not even you know it was I had I had doubts, right? That it was like uh a miracle drug. Again, I don't know where you guys stand on, so maybe I just stepped in. I don't know. No, no, no. But but I'm thinking, wow, that you know, and if it if we're talking about a private insurance company and and people who are willing to pay it, like like let them use it. Like, like again, you know, turn the turn the review and the let's get rid of the barriers on that. But once we're talking about taxpayer interests, there's a there's a taxpayer interest there. Once we're talking about public programs, there's a taxpayer interest there. And I couldn't help but think, because I know from reading and listening to Vinay Prasad for years, I know that even if he's not allowed to make a decision based on costs, it's gotta have been in his head, right? Because the this huge price tag on this thing with the marginal benefit. And I know that he hates probably the thing he hates most is like a pharmacome farmer company coming up with something that's like a minimal benefit and really expensive, right? Like he he's always railing against that. And um, so anyway, the the the you know, the the thing that I've been thinking about all this time and I haven't published anything on it yet, but is this kind of like proposal like what about a reform that that has that that kind of distinction, which allows the public payers or allows the FDA, when you know kind of defending the ground of the public payers, to to take to take into consider into consideration not just you know safety as they always probably should and but and efficacy, but like also like even cost, right? Like so that's the turning up the dial. The one thing I I would one additional thing I'd say on this is that just sort of to reiterate like the idea that like you've got a right to bring it to market, but you don't necessarily have a right, I would say, to bring it to a public program and and expect for it to get paid. Especially when there's no like real I mean, they can kind of choose what they want to charge for it, right? I mean, there's no like real review or or competition. It's not again, it's not like a market price. So that's the right. So that's why I push against the idea that that any pharmaceutic should just be able to sale anything through if we're talking about a a public payer.
SPEAKER_00So right. So right now the problem the part of the issue is that the FDA's um affirmation of efficacy translates to a mandate to for private and public payers to pay. Right. Because then now the now the hot potato is on like Blue Cross. It's like the FDA, which is like the world's greatest organization that says things work or not, is saying this works for my rare disease, and you, the Blue Cross, in are not paying for it.
SPEAKER_01So that then you're still for drugs, though, not not for technology and procedures, right? Because those have a separate pathway where you have to get a CPT code to actually get paid. So it's interesting, there's like a duality there. Yeah.
SPEAKER_00That's a great point.
SPEAKER_01Sorry, go ahead.
SPEAKER_00But sticking to the drugs thing for for a minute. You know, so yes, uh, exactly. So this novel drug therapeutic. So the issue you see, Jared, even with the model you're talking about, is that, you know, again, you're gonna have the uh you're gonna have this massive campaign that says, oh my god, the FDA is saying this this works, and and you are not paying for this for my for my rare disease. And uh, you know, IBC, we all know what happens. I mean, insurance companies are like the worst in the world at like actually not paying or negotiating well. They're just like, okay, well, whatever, we'll pay and we'll just increase everyone's premiums and shrug our shoulders and be like, oh, what do we do? Everything's everything's going up in price. Oh my God. So I'm not entirely sure. I'm not entirely sure what to do. I would love it for the FDA to be like like some version of the consumer reports. You know, it's like, okay, you know, you gave an gave your opinion on whether it works, and it's it's one of a number of opinions, except it's like saying, Oh, the government's just negotiating on prices. Like the government is not negotiating on prices, the government just tells you what what to do. So the government giving an opinion is very different than like consumer reports or some private group gripping an opinion. So I quite I don't quite understand how to make a system, which I completely agree now, and I think many of us seeing what's happened in terms of literally you have regulators being fired because they're not allowing drugs that are like it's not even close. I mean, there's lots of gray area in medicine. I mean, you know, maybe it works, maybe it doesn't work. I mean, this is like, oh my God, really bad cases. I mean, the first time, just to talk about your gene therapy uh with uh muscular dystrophy, the uh elevatus case. I mean, this is a drug that was approved by the prior administration. And despite the data being bad, despite number of FDA folks saying, whoa, this is like this is not this is this is bad in the sense that we don't know what the efficacy really of this is. And oh, by the way, there's a pretty severe side effect profile because you know, a lot of folks' LFTs, liver numbers go up a lot. It was ext the approval extended not just to the kids in the trial, but beyond the kids that were in the trial, because of course the rare disease community wanted not just the kids in the trial to have access to it, they wanted more than that to have access to it. And so it was given access to it, and then a number of kids actually died. And then when, you know, Prasad uh attempt uh Prasad led CBR, I don't know how directly involved he was, but he was head of the CBR at the time. When he goes to essentially take the steps to pull the drug from market, there's just pandemonium, like planted stories, Laura Loomer talking about Prasad was a socialist. I mean, it's nuts. It's like, oh my God, this is clearly like lobbying dollars planting stories, and there's this huge news cycle that's created because a drug that shouldn't have been approved went out and actually killed kids, right? And and just to pull that drug from the market, it's like, and this is not like Pfizer, this is like some small biotech that's like, you know, I don't know, some 4 billion, 5 billion revenue a year, which is not nothing, but just to show you the numbers. So sorry for the long-winded uh thing, but Jared, I I still don't understand what one does that. Because by your model, the FDA says something and it's guarding the public payer, something like NICE, which is what the UK has, saying, okay, this is marginal, so we're not gonna pay for it or something, right? But in our current model, in our current model, you know, IBC I think is still gonna be compelled to pay it if the FDA gives uh gives a thumbs up.
SPEAKER_03You're right, it's tricky. The straight up laissez faire capitalist position would be what what we should be doing is is uh is advocating for the abolition of the FDA. And I mean, okay, so but how again, how how far have people gotten on that in the past 30 years? Because I've I've heard that for a long time. You know, I I don't I don't see people making progress with that. And so, and and and you know, I'm trying to me and my colleagues at uh at CMH, we're trying to, you know, keep that, keep the ideals and keep the principles alive and clear in at the same time balancing being actually effective and actually helpful with with today, with what we have today, right? And and and in like a reasonable time frame, you know, a couple of years down the road, you know, that sort of thing. Not not identifying something that we might get in might be an ideal 30 years from now. Uh it's so I don't know. I mean, that maybe the one other thing I've heard, sort of putting all the other sort of options on the table. One other thing I've heard, it, and it comes from uh Robert Greyboys, who's uh actually a Merkay, this guy and uh and uh George Mason guy, retired now, but a a good health economist. And and I remember he was talking about the um sort of the European model there, where we would have, I guess what they do over there, they they've got it, they've got multiple review organizations. If you're a a pharma company and you get a a rejection from one, you can go to the next one and kind of repitch your case and try to get, and you only need one of them. I think it's it works something like this, like where you only need one of them to say yes in order to then like gain access to that market. It's it's sort of what would you call that, like a federated system or something like that. That's the that's maybe the one other kind of model that's distinct from the couple of things that we've talked about so far that you know maybe is something to look at. So uh yeah, I I agree. It's it's a tough question. I think a lot, I'd like to think that a lot of what we're seeing in the past like 12 months that's that seems to make this like particularly bad is is sort of a um more of a symptom of our struggle here with democracy and and and the the sort of like quality of discourse and the types of people that we've got in in the administration. By the way, we've got some good people too. I'm I'm a fan of some of the the nominees, but um, but I I think that we have a a pretty toxic culture though, where you know, hey, if you don't if you don't play ball, you're out and um and you know this and it's pretty clear what the what what the White House wants out of some decision that comes up. I I think that's that's pretty ugly.
SPEAKER_01You're probably the most pragmatic libertarian I've ever heard. Talking about what what we want, but also what's possible. So you I think you bring up a pretty good point that we have a lot of this, I guess it's almost been labeled economic populism, right? W from both the left and the right, where the instinct is for government to do more to fix the problem. I absolutely love your pinned tweet. You say if a policy idea sounds nice in the abstract, but doesn't take into account implementation challenges, second order effects, or the possibility of unintended consequences, then it's actually a bad idea, even more if it violates individual rights. I think that that's brilliantly put. And I think about that a lot when I see proposals out of both sides of the aisle. For example, so you have this breakup big medicine bill, Josh Hawley and Elizabeth Warren teaming up. Um, I mean, what are your thoughts on that specifically? And then just this general overarching idea or instinct to just have government do more to fix the problems instead of rolling back regulations.
SPEAKER_03Yeah. Yeah. Uh well, thank you for the for the kudos on the uh on the pinned tweet there. That's been my, I don't know, my my profile tweet or whatever they call it, pinned tweet, I guess, for for a long time. But what I really am trying to emphasize in there is the individual rights part. But I know that in order to get heard, I've I've got to say the other things, right? Because because that's like the, you know, that that's the that's the policy profession, right? But I I really want to get the rights message through. So sometimes you have to what put the put the pill in like a when you're feeding a dog a pill, right? Yeah. Spoonful of sugar, something like that. Yeah, right. Yeah, exactly. No, good question about uh the the breakup uh big medicine stuff. Uh so my my colleagues uh Colleen, um, Colleen Smith and uh Rayner Schur. Um Rayner is a uh a PhD in um in like uh philosophy of medicine, and Colleen is an emergency medicine physician. She's in New York and he's in Baltimore. Shout out to them. They're they're awesome. The the three of us sort of form the core team. And then we have like contributors and collaborators and stuff, and then of course they are board and stuff, but uh like we're sort of the core team. They've actually written a couple of articles on this like break, you know, breaking up big medicine idea in the Holly Warren bill. I think the the main thing there, it it it it kind of exactly what you said, is that there's this, you know, whenever you you you see something that doesn't seem to be working right or or is you know yielding the wrong incentives, it's go in and regulate it. And that's why we don't really love the the you know breaking up big medicine thing. We like to actually celebrate it. We we I think we took the opportunity to to like kind of praise some of the benefits of like vertical integration. I mean, why are we so much why are we so against vertical integration? It works so so well in lots of other places. I drive a Nissan pickup truck. I go, I I I I I go to get it service at the same place where I bought it. So they've they've got their sales, they sell the the cars, and then you you know go and you that's where I get my the service done and the the tires rotate and the and oil changed and everything. We we're surrounded by vertical integration. There are ways I'll sort of grant, there's always like a kernel of truth, though, tricky thing too, because there are ways in which because the healthcare system is is so frustrating in how it is to deal with, uh, you know, like like PBMs. I I struggle what to think about PBMs. I'll I'll I'll be honest. I haven't really written on it yet because I'm still sort of trying to sort out the good from the bad from the ugly in in that. You know, I kind of like what uh like Mark Cuban's doing with cost plus drugs and you know, good RX has been around and stuff. I I liked some of the the transparency stuff that they achieved through um you know market means. But like, do I want to break up, you know, do I want to use regulation to to break up the something that I might not like? You know, like because PBMs are a big part of the the the that breakup big medicine, you know, bill. They're like clearly the target in in that. I think I'd rather let market let new competitors enter and sort of like outcompete some, you know, if there's if there really is a bad business model there, you know, with with uh, for instance, the PBMs, let's let's expose them to some competition, which would probably, you know, drive out whatever bad behavior may or may not be happening. And I I'd prefer to see solutions like that than than something like what we've seen from Holly and Warren.
SPEAKER_00Yeah, it's it continues to not well now not be surprising that everyone wants the government to fix things. It seems like we have a two-year timeline, you know, to do so to show that you've done something so that you can then go to the electorate and be like, see, look, look, look at what I have done. I have, you know, moved the lever of the Leviathan to do X for you, you know? So and and it you know, I I don't know. Is that still just a fundamental failure of uh democracy? Because I mean it's fascinating to me that um Indian Indian politics a lot of times is driven by like, I will reduce the price of potatoes, I will get you onions less and but it's not like I mean our politics is like, oh my god, you know, gas prices have gone up 50 cents. You know, like what like if gas prices stay up more than 50 cents than what it was six months ago, well, there goes the midterms. Yeah.
SPEAKER_03What? Yeah, I'm not sure our system is that different than the Indian system. No, yeah, exactly. I'm I'm saying your example isn't that far off, right? I mean, we just maybe we talk about different commodities and and different burning platforms, but it it still is like uh what's your reaction to the to the recent platform? One thing I'll I'll add too that's also like an additional thing to be for us all to be frustrated about is that a lot of times when you start, you know, like mapping these things out on paper and and stuff, you realize like you need multiple changes to happen at once in order for for like real reform to happen, you know? Like you know, you you you see something happening with like prices being out of whack. And then so you say, well, that's due to there often isn't like one single thing that you can do that's super targeted that's just in that domain that would that would like fix it. Sometimes it's multiple things. A lot of times these trace back, for instance, to like, well, it all starts with like the uh the tax preference that we give to employer-sponsored health insurance, for instance. Um, like so many things would be kind of different if we didn't have that. So some some like issue five deviations away is act is is getting messed up because of this. Michael Cannon from Cato calls it the original sin of healthcare, giving tax preference to employer-sponsored health insurance because now we we buy we buy more insurance than we probably need. It locks us into our employer, et cetera. You know, so like it causes other things downstream, and then it it becomes really frustrating and hard to reform.
SPEAKER_00Right, right. Correct. Yeah. So so let okay, let's let's talk about some more specifics. Uh prioroth. All right. There's a prior authorization is on physicians' uh uh list of things that need to be reformed all the time. It is the bane of everyone's existence. And uh Anthony and I actually, I mean, believe me, nobody hits the process of prioroth more than me and my staff. I run a small shop, and oh my goodness, it is it is a headache to try to get this through. And a lot of times it seems like you're just, you know, people are just trying to gum up the works, um, if you will.
SPEAKER_01Yeah, it's a nightmare.
SPEAKER_00But but that being said, it's fundamentally, it must exist in some form or the other when you have a third-party payer. Like I it just to me, it just I can't see anything existing. Sorry, I can't see a stable system otherwise, right? And traditional Medicare is the classic example. Look, you know, one of the nice things about traditional Medicare, despite the fact that, you know, they have a set, you know, communist price. One of the nice things is that, you know, traditional Medicare with some supplemental plan, there's no there's no friction. You know, uh, you file a claim, uh, you get paid. Apparently that's true for uh billion-dollar home healthcare organizations in Minnesota as well. But uh and but that's not a stable system, you know, Medicare. That that's why that's why Medicare Advantage uh you know exists, because now suddenly you've created legislation that allows some other someone else to be able to say no and create some of this stuff. And you know, every every two years, every year you get these people trotting out being like, we are gonna do some prioroth reform and stuff. You would argue that this this is always bound for failure. People are always gonna be drowning in prioroth, correct?
SPEAKER_03I mean it's it's it it's hard to avoid when you have a third party system, right? When you when you have uh because it's a principal agent problem, you know, the agent there is supposed to be the the healthcare and the health insurance company, they're they're supposed to be acting on behalf of the of the principal, which is the patient in this instance, but they also have this sort of self-interest of denying things because then that's that's better for for dollars in uh in certain contexts, right? So that's once you have that dynamic, it's hard. I think um so yeah, I mean it does does it always travel with um with third parties? I I I suppose it does. I think there are some ways that we've made it worse though. Um one thing I would say is that look, we've you know, we've uh we've pushed all of the cost consciousness seemingly onto the insurer and the insurance companies. Um we've kind of built a system where uh you know we we've we've reassured patients like, oh, you don't need to worry about a payment at the at the point of care. And then and when that that sort of cost consciousness responsibility fell on to physicians, physicians started saying, Well, uh, look, we I just want to deliver medicine. I don't want to worry about the the the complexity and and craziness of all that. Just let me do good do good doctoring. And so then they that got pushed then to to the to the insurance companies. It's you know, but again, the somewhat sympathetic part of me says, well, they've got to do something to if they said yes to absolutely everything, it would cause premiums to go up. And we wouldn't like that either. So it's sort of like, which, which way down the road do you want to kick the can? You want to kick it down this way a little bit further or that way a little bit further? Well, and and and so I I alluded to the idea that maybe there's a way of like lessening it a little bit. And and I would point there to just relying a little bit less on on insurance. And what I mean specifically is like the the super comprehensive care kind of in in insurance. If we did, if we paid a little bit less with insurance and a little bit more with uh, you know, kind of more directly, and that just leaves fewer decisions to even go that far to that that have to get you know sent to insurance and then come back, um, which is you know a way of of of reducing it a little bit. Uh, I think I think that's one thing. But but again, that's that's that gets back to like a like a cultural kind of thing. That's I can't name necessarily a like a small specific, you know, surgical policy. I don't mean surgical, like literally clinical. I mean like saying something that's very specific. You know, I can't name like a policy lever exactly in that system. But I so that's where we we would then like step back and say, let's let's communicate a a different kind of vision for how how the the culture of uh of of pursuing health should be, right? And and like a a different kind of culture of of pursuing health where you're in charge of more of your own dollars and you and your doctor are deciding what you have more of the say into what you upgrade, what you go for and what you don't go for. And then just fewer of those decisions ever make it to insurance. Only the really you know expensive, the only the really catastrophic ones get that far.
SPEAKER_01Can I actually push back on that a little bit? Because it seems that more and more the trend is high deductible plans, right? And the thought is with more cost sharing that that should be happening already. So why with more people taking high deductible plans these days, is that not happening? Or are people just the the newest trend I see now is people just exiting insurance altogether and saying, I'm just gonna, you know, pay cash out of pocket. But why is that not why has that not moved the needle? Have we not reached a critical mass yet, or is the system just slow to adapt?
SPEAKER_03It's a great question. I I think what it is actually, it's it's a little bit of like other things have to change too, right? Like, like the the whole the whole idea of being able to get a get a clear price on things and and have those pricing discussions. Like a lot of p physicians, you ask them, you know, well, what what does that procedure cost? And they they can't tell you. And I understand it's understandable, right? Like if you were to tell me that you're in the same situation, I would be very sympathetic. But like if we want to bring about some change, we need to change that too. Like we need the culture of uh of just dealing with prices to become more common. And until that change catches up as well, we sort of refer to these as like cultural things because it's it's more than just like a particular policy existing or not. It's it's people getting comfortable with the idea of the patient spending their money of going up, going up to your doctor and asking before you say yes to something, you know, oh well, what does option A cost? What does option B cost? And then you know, coming to a decision on that. For that to happen, the physician needs to be able to quote some sort of price, right? And and if you're just not even thinking about that, or or if only if only a couple people per week ask you that question, it's it's not enough, right? It's sort of the critical mass idea. It's not enough for you to like go find, figure that out, you know, and and run your numbers and and and start start practicing in that way.
SPEAKER_01So can is the answer to legislate price transparency, or would it be more effective for this to be a ground up phenomenon where people demand price transparency, right? Because nobody's legislated price transparency in like buying a car, right? You just wouldn't go to a car dealership, buy the car, and then pay the bill six months later when it shows up.
SPEAKER_03Right. Yeah. I'm actually so is as much of a fan and I'm banging the drum for prices. I'm actually not that big of a fan of price transparency, only because uh mainly because I don't think it really works. It's easy to game. Strictly speaking, it's it's it's kind of a sort of a violation of the rights of the of the the providers. I mean, if they if they want to, you know, do business in a way that's really opaque and not very friendly. I mean, I I suppose I I'd like to think if I was a you know physician, I wouldn't practice that way. But you know, I guess they should be allowed to do that. But yeah, and and and in general, we haven't seen them to to be very, very effective, you know. But there's there have been the price transparency laws, and there's always seems to be some way around it. Or, you know, okay, you can comply by, you know, sticking it on some, you know, uh some page on your website that takes 17 clicks to get there. And once you get there, it's completely inscrutable.
SPEAKER_00So the fascinating thing is that you have some of the biggest laissez-faire capitalists supposedly who argue for this in the healthcare space. Like I really do get the impression a lot of times when I is certainly in biotech world, man, these folks want federal legislation that mandates third parties pay the full price of their product. That's what they want. And these are like the biggest, you know, obviously they're, you know, in the private markets, they're raising funds, Series A funding, B funding, blah, blah, blah, right? Um, and yet when it comes to healthcare, they're like, well, no, no, no, we we need our products. Well, if the FDA says it's oh it's gonna work, you must pay for it. And then and they're all they're almost offended. They have like a it's a moral thing that you you can you you you can just see the blood pressure rising if somebody was to say, what do you mean you're not going to pay? What do you mean you're gonna give the patient a high deductible? Which means the patient feels the cost, which means my product may not that they have this condition and they should be this cut. You know, you get they get very very, very upset. So it's uh it's certainly interesting to uh see how that kind of conversation takes place on on the ground.
SPEAKER_03Um and then you just not all business, not all business people are capitalists. I'll tell you that.
SPEAKER_00Well, they are capitalists, but they are. I mean, what do you what do you call it? So anyway, so Mark Mark Cuban is is a great is another really interesting example, right? Mark Cuban is doing cosplay drugs and he's like advocating for you know a free market and like you know, let's get, you know, you know, employers should directly find out the prices from me. Here are my prices, I'm publishing all of them, right? No one's forcing Mark to do that. He's doing that on his own, and he's doing that as a competitive thing, which is what you know all three of us would love, right? But Mark also then wants to compel everyone in the healthcare space to release what their line item expenses are. And it's like, I mean, sure, but well, I get I guess, but I mean, I don't, I mean, I don't want, I mean, do I want people to know exactly what like what my costs are? Like what what does that mean? Like what my mortgage is or like and or or I mean like I know what he's saying, like how much I paid for the echo machine and he wants all those costs to be public and private. It's like that doesn't work in that that that is not a requirement of any other private marketplace. And if I went and and if I went to every NBA person, NBA owner, and said, I need to know exactly what what your prices are. These are private organizations, not public. Why? I mean, that's not that that's not okay, isn't that? What are your thoughts on that, Jared?
SPEAKER_03I I I I I agree. He's a mixed case. Uh generally, do I like him more than I dislike him? Yeah, I I I I I I believe him a little bit when he says, like, oh, I'm you know, I'm pro I'm I'm I'm pro-capitalist. I like free markets. I mean, Hillary, Hillary Clinton said she liked free markets, right? So and and and and so they don't always see it as a total contradiction when they say, oh, I like free markets, oh, but um I'm going to I'm gonna regulate this and this and this. Like, like if I ever take a position where I'm I I I appear to be mixed or something like that, it's it's probably because I'm talking about different uh like time uh um stretches or something like I I'm I'm taking I don't know, I'm I'm I'm I'm accepting a um I don't know a mixed system as a step towards something that's going to be like a clear strategy. You know, this will get us towards something. But they don't that that's that's different from like when when uh Obama or uh or Hillary Clinton or some something like that. And definitely not all well, yeah, yeah, I'll I'll I'll leave it like that.
SPEAKER_00So so yeah, and and you know, it's well, it's it's an it's uh, you know, the next thing I wanted to we've touched on this before, but I definitely want to just just clarify, right? Um, you know, Section uh 6001, you know, the single most successful anti-competitive piece of healthcare lobbying in the past in the uh post-2000 era, you know, the the American Hospital Association uses the regular state to lock in an in incumbent incumbent market structure, you know, under the guise of, you know, hey, patient protection. And it's literally essentially a wealth transfer from everyone, because of course that it created this type of consolidation that allowed these prices to kind of rock it up, but also a wealth transfer from physicians to hospital corporations, you know, and it's you know it it's passed uh, you know, despite physician groups kind of opposing it. So if um so but a lot of the reason for that physician ban has to do with this self-referral concerns, you know, the Stark law, which obviously everyone is constantly thinking about in the physician space uh in terms of are we violating Stark Law? But so what how do we how does one address the physician self-referrals, which obviously is something that is a concern for the public and for the public payer, right? The public you were talking about having gatekeepers and safeguards for public payers. What's the what's the safeguard? If physicians did own hospitals and physicians and you took away Stark Law and you took away the self-referral thing. Jared, how would you protect the public purse given that we can't wave a magic wand and get rid of the public uh welfare state?
SPEAKER_03Uh um yeah, I think I I wrote I wrote something on this a long, long time ago, which when I went back and and uh read it, it was like, oh wow, that that's that's like still relevant. Um and uh so I republished it like not too long ago. And uh and um it's uh yeah, I no, I I I can see, I can kind of understand. I'm I'm willing to like grant a little bit of the of the um the concern about okay, would would there be some, you know, would there be some overutilization, that sort of thing? And would there, you know, with with there being a public payer involved, isn't there uh again, isn't there sort of like a taxpayer interest in? Okay, so but I I just this strikes me as just such a blunt instrument to the the the the de facto ban is what I mean. That's such a blunt policy response to something that's probably um much uh you know relatively small potential issue. Um and that's why I've you know I mean I've called for it to be to be changed, and it's you know something that we we kind of key consider and and and and monitor. I don't know what you know if what kind of activity is being done on this. Uh actually, Dr. Giorgio, didn't you uh recently uh give some testimony on this? W was it on this or was it on something else?
SPEAKER_01It was. And that was gonna my question to you was gonna be is it Stark Law is only applies to Medicare, right? So you Stark Law and the Section 6001 don't apply to private insurance. Um so for what number one is why do you not need Stark Law and a ban of physician or hospitals in private insurance, but you do in public insurance? And part two to that question is if Medicare Advantage is essentially a private intermediary, why do you need Stark Law and Section 6001 in Medicare Advantage?
SPEAKER_03Yeah. Yeah. Or do you I I think the question on your first question there is is think the only reason that you would need it with a public player and not not you're this wouldn't even come up in in the private payer is because because there is that sort of like fear of like a taxpayer being fleeced here, right? But when you're talking about something that's purely a private, you know, interaction, that is that's a that's a straight up you can you have options. Like you can, first of all, you can you can go to if you're a patient involved in this situation, you can go to different physicians, you can go to you can get a different uh possibly you can get a different uh payer, right? And so you can you can extricate yourself from that that situation, you can go to different providers.
SPEAKER_01Or is it that that the private payers also have utilization management, utilization review that traditional Medicare lacks?
SPEAKER_03Right. That that's too right, yeah. So they they they do the they do that kind of review. And they're and actually this brings back in like the the the prior authorization stuff too, right? And and so like they're that's more visible in the in the private world than it is in the in the public world. And in in Medicare, it's seen as um sort of like politically ugly, right? And so they just let the you know, let the spegot go, right? Um and so that's that that's those are some of the differences there. I forget what your second question was.
SPEAKER_01Well, so if you have if you don't need Stark Law in private insurance, and that Medicare Advantage is essentially a private intermediary for Medicare, would it make sense to then get rid of the need of Stark Law and the and the ban on physician and hospitals within Medicare Advantage, at least if you're gonna try to deregulate some stuff. Would that be safe to do? Maybe leave it in traditional Medicare for now, but it take it away from Medicare Advantage and by extension, Medicaid managed care as well?
SPEAKER_03Yeah.
SPEAKER_01It's uh that seems uh I hadn't hadn't thought of that, but um that seems like uh I don't do a lot with like Medicare Advantage, but um that seems like a possible approach to it's one of one of the things I I talk to my physician colleagues who despise prior authorization is that if we're going to get back to the point where there's large-scale physician ownership of private practices, of downstream revenue sources, and of hospitals, I think that my view is that we need some sort of trust layer in there. And if Stark Law or if if a private intermediary such as a private insurance company and utilization management is a means to get there without needing a blunt tool like Stark or Section 6001, I think that is a preferable avenue. There's a lot of problems with Medicare Advantage. I'm not gonna say it's perfect, but at least you know, by having that private intermediary, you don't need these blunt prohibitions like Stark and Section 6001. Right. Right.
SPEAKER_03Any kind of now uh the other thing is there's been talk, right, of Medicare giving Medicare dollars like directly to patients, right? There could be some kind of lever there where that helps this situation. Because again, when you give like the best utilization review there is is a system where you've got patients spending dollars with with providers directly, right? And you're not doing going even the route of the third party, right? And so the more that if you were to somehow, I don't know, like reduce the keep the overall Medicare sort of benefit as of even even just keeping that constant, but making it less about coverage and then cashing out part of it and giving that to patients in some form of some sort of like you know, flexible spending account or a health savings account or something, that that could work. Again, now that that could be a step in the right direction. It does sort of again kind of require, I think, maybe like a little cultural change though, too, because like if you if you then try to to make that system work and a and you and you walk into a um a physician's office and you start as a patient, you start asking them pricing questions and they're not ready for that. That's that system's not going to work too well. So it kind of comes back down to the again, like the the patient culture about around prices as well as like the physician culture changing around prices to match that. We won't get out of some of these traps until both of those parties are are willing to talk prices a little bit.
SPEAKER_00All right. Two two other two other questions. One is um about private equity. Why should physicians not hate private equity?
SPEAKER_03Why should physicians not hate? Okay, so I I did a um I did a uh kind of a deep dive on this uh about a year ago. Uh and I went I went through all the claims about private equity. Um and my I I I sort of did it as a first take strictly from a like looking for rights violations. I really couldn't find any. Now I realize that that's sort of for some people they're like, well, I don't care whether it's rights violations or not. I just want to know like, is it is it sort of good for my practice or not, or something like that. But I wanted to do that kind that level of review first.
SPEAKER_00And I I mean I I recognize that one of the knocks comes from younger physicians that are part of these, uh, you know, part of these whatever, four or five uh ten-person groups. And you have a bunch of younger physicians, you have uh, you know, uh a few folks that are in an ownership model and they're close to retiring, and private equity comes, gives them a whole whole bunch of cash whole, you know, uh uh uh cash to buy the practice. The the the senior physicians retire in two or three years, or they have this big cash payment uh settlement, and then the younger physicians kind of end up getting a little bit of the raw end of the deal because now they're working for this large private equity group with uh you know administrators and stuff, and they don't have any lever to necessarily become owners. Every private equity deal is of course not the same, but that is the knock on it. So does that violate uh it it's it's uh I I didn't I haven't read your your your paper on private equity. But does that violate the rights of the physicians to kind of you know pursue their goal of partnership and the goal of owning?
SPEAKER_03I didn't hear I mean taking it literally, I didn't hear a rights violation in there. Yeah, I didn't I didn't hear like real actual you know coercion, uh I didn't hear fraud. And and and like that's what I was looking for on my review. Um I was looking for all the practice, even things like like people talk about like the land sale lease back stuff, right? Like they'll a private equity company will go in and they'll buy like a hospital and then they'll they'll immediately like sell off the land and then start renting it back and stuff. And and they like these might, these might be good or bad management managerial decisions. I don't know. That that's a business question, almost like an empirical question. I still, even if it's a bad business decision, I I can't find a rights violation in there. And other on down the line, I sort of went down everything I could see, even things like claims about like, okay, the um uh private equity will buy a medical practice and then they'll they'll change the culture of the practice and make it a miserable place to work. Still not really a rights violation. Like it might be a bad thing. And so I'm leaving room for for it to for for it to be clear.
SPEAKER_00It's not a rights for the for the physicians that now are owned by the private practice uh in terms of it, you know, because the the part of the issue is say, you know, say you have an ophthalmol group, right? There there's this fair amount of infrastructure cost when it comes to when it comes to you know running that operation. You know, there are maybe you know millions of dollars worth of equipment and stuff. And so, okay, private equity takes over and gives a sweetheart deal to, you know, three or four senior physicians who kind of push this through. And now you have a younger physician who is like, okay, great, I'm just a salaried employee with no hope of ever becoming owner, and I can't just create my own, you know, create my own, you know, and step out because that requires you know capital investment, requires getting a bunch of opt opto folks together to be able to make that work. I mean, that's that's a significant barrier to uh a significant barrier, right? So why is that not a rights violation for the younger physicians within that group?
SPEAKER_03Aaron Powell Yeah. So because presumably the contracts allow that. I mean, if they didn't, they'd be able to sue. And whatever contracts that are in place, the employee at will, or whatever your whatever arrangement you've got, that's all written down. And so again, I'm I'm I'm totally leaving open that it might be miserable for people and it might be like you might even like see of see it as a bad trend. But on my original uh kind of like look at that, I was looking for like literal rights violation. Now, if you're interested, I did find one that I was willing to like throw the flag on. Okay. As sort of being the referee. And that gets down to uh certain instances, like if you if the if the private equity company acquires some, like let's let's say a hospital, and then it it extracts legally, because they've got really good lawyers, they know how to do this legally, but they they they extract a whole bunch of capital from it and you know they they can like loan against it. It's it's really kind of weird stuff, actually. It's pretty some of it's uh pretty counterintuitive how it works, but they like borrow debt against it and everything. And let's say they put that, they put that like hospital or or or facility in in such a bad situation that it that it has to go bankrupt. Now, bankruptcy laws are a little bit of a gray area. And if you're I suppose if you're if you're purposely putting something in in into bankruptcy position in order to like get out of owing some vendor a whole bunch of cash, or or there's even been I I've seen uh claims about like this happening and then like leaving a large real estate tax bill with the city and like you know, throwing that into like bankruptcy and things like that. So like if you're getting out of, if you're if you're running into the into the ground, or even maybe maybe maybe it was an honest attempt to make it work, but you but it failed, but then you you uh you sort of like extract value as the ship is sinking, that could be there's something called a fraudulent transfer. And it's sort of like the the the the um the the analogy that's very easy to understand would be like it let's say uh I know I'm about to go bankrupt, got like uh you know, I've got a nice uh bass guitar there or a piece of artwork or something like that. And I just give it to you. Yeah, like you're my friend and I just give it to you so that that way my creditors can't uh you know properly get it and um uh and and I see.
SPEAKER_00So so the rights argument is is is is kind of narrow in the sense that you're looking for fraud, contract violations, you know, kind of getting getting out of payments that you that you could have made. You know, in in the case of the physician thing that I was talking about, it's like, okay, you're you're a big boy, you sign a contract. If you if you didn't if you wanted to sign a contract that said you were not allowed to sell private equity, that's what you should have done. So uh you know most physicians who sign contracts out of uh training, they they think they're like you know, 20. It's like you know, somebody should uh somebody should have done this for them. So uh it's it's something to kind of think about. Um the uh Anthony, go ahead. Sorry.
SPEAKER_01Well, I was just gonna uh if we were getting to the end, I had one one last question about what you you would say, just in the broader topics of free market, what would you say to someone who claims that a free market always leads to monopolies and cartels exploiting those who can't make money in the market? But they just don't. But a lot of people think they do. A lot of people think that that you know free markets always end up that way. So what I what's the basic way to just explain that to someone who who doesn't get that point?
SPEAKER_03Well, like look, I I mean I'm old enough to remember my space. And then, you know, now Facebook, you know, they they took them over. Now who uses Facebook even anymore, right? Like it's uh we're on to like social media things, things there's always if we allow actual competition, we there will be constant pressure on on businesses to continue to be relevant and to continue to innovate. And I think that holds true. I you know, I just used a silly uh you know web example, but uh I think that holds true even in in healthcare. No, no, there can be cases where you if you don't let competition ever see the light of day, and and there we may I think we have a risk of that in healthcare because we're so good to incumbents sometimes, which we shouldn't be always. And we allow them to, you know, through rent seeking and other things, uh, to to sort of protect themselves against competition. I think that is a risk. And so now I don't know that that's going to lead to, you know, one hospital being the only only hospital system in the whole country or something like that, and then like a literal monopoly like that. Healthcare is certainly, you know, kind of regional and everything.
SPEAKER_01But does that does that protectionism, does that not become a positive reinforcement, right? Where now you have more lobbying money to advocate for more protectionist policies that gives you more lobbying money. I mean, is there a way to break that cycle without just some libertarian coming in and slashing all the regulations?
SPEAKER_03Well, a system that's rife with uh protectionism is not a free market, right? And so so if we're we're then talking about two different things. Like I'm talking about a free market where there where you can't buy protectionism, right? Um but but your your question is is good, which is like, well, what about like the real world, like right now, where there is some protectionism? How how do we avoid that? I I think we need to raise the alarm on the protectionism and call it out. Um and and that's that's part of what we we try to do, Chrissy.
SPEAKER_00All right, foreign train physicians. You have spoken out in uh in support for uh lowering the requirements for foreign transitions to come here and practice. I wouldn't say that. Oh, okay, sorry. Then here, clarify, clarify your position.
SPEAKER_03Well, the our the the specific thing that we're we've talked about, and I've I've I've testified uh a couple places, no in New Hampshire and Vermont, actually. Yeah. Is it not I don't see it as a lowering, I just see it as recognizing something that they've already done. What what we're talking about here is um how do you know? Uh how do you know what they've done? Okay, fair question. Let me get to that. But for the for the for the listeners here, uh, what we're talking about is the requirement that's uh pretty universal that if you are a foreign-trained physician, and and we're not talking about like an IMG who just graduated from like a Caribbean school or something. We're talking about like some, you know, like you're coming from Germany and you've been a surgeon there for five years or something like that. If you come over here, you've got to re and you and you want to continue to practice medicine, you've got to redo your residency. And, you know, we're not just talking about like making sure that you pass the exams and stuff, but you actually have to spend the two, three, four, whatever it is in a particular state years in a residency program. Seven. Yeah. That was that, was that yours? Crazy.
SPEAKER_02Yeah.
SPEAKER_03Um and and you have to and so what we've advocated for is that you don't have you shouldn't have to redo your residency, that you should be able to, you know, by showing the basic requirements of a given state's medical license rules, whatever they are.
SPEAKER_01But how how do you how do you judge the quality of the residency, right? Are you gonna trust someone coming over from I don't know which country I want to upset now?
SPEAKER_00But you can't do not say Pakistan. You can't do it.
SPEAKER_01It's not gonna I was gonna say Siberia or something. The the neurosurgery program of who knows where are you gonna like how how can Americans know that that residency I mean, obviously someone comes from Germany, yeah, they're probably well trained, but there's a lot of a lot of places where you don't really know the quality of the residency program. How do you know that a neurosurgeon coming from that country is up to the same standard that uh a neurosurgeon with US training is?
SPEAKER_03Yeah, sure. Good good question. What we've talked about in the states where we've been kind of involved in testifying and writing articles about and sort of help trying to help movements and stuff, they have requirements about uh supervised practice. So they they come over here and they they have to get employed by somebody, which is going to involve like a background check by that hospital, for instance. And you're you're practicing in a team setting, in a team environment in a facility. And that's not the same as a residency because you can you're you're not restricted in like what you can do and everything that leads to a a license, a a regular license after in most cases it's like two years. And that's we we would say that that's actually probably a a more you know, having a couple of years in person working side by side with somebody give you a better idea of whether they are truly as qualified as they say they are, rather than trusting something that's written on a paper.
SPEAKER_01It does, but what what's to prevent the the hospital from just using that to get two years of cheap labor? And then after two years saying, yeah, go back to Tajikistan, we're not gonna take you.
SPEAKER_03Trevor Burrus, Jr.: Medical liability is one one small check on that, a little bit, right? They have to they have to pay for that. And if there's a if there's a s you know a serious risk there.
SPEAKER_01But I mean, getting two years of cheap labor is pretty good. Like if you look at residents, so residents are essentially very inexpensive labor, and hospitals love having residents around.
SPEAKER_03Right. Yeah. And the argument could be like, look, uh wouldn't they be willing to work at a the at a discount, right? Because they're yeah, if it's a path to a US license.
SPEAKER_01Yeah.
SPEAKER_03Yeah. And that it is sort of like the, you know, it's it's a kind of a waste of human capital to have, as we do in this country right now, you know, uh physician trained physicians who are driving Uber or you know, doing DoorDash and stuff, like like that's their gig because they don't want to, you know, do uh you know, restart over or with redoing their residency. Or they're or they go and they, you know, they they work as a nurse. Okay. Which they can be a really good nurse, but again, it's like a a lost human capital.
SPEAKER_00Jared, but it's hard enough making sure that the current system that we have, that we control, um that we are graduating people that are highly competent. Um, uh Dr. Beth is the example that we I think we mention every show is this neurosurgery doctor that somehow made it through a US US uh neurosurgical residency and uh you know maimed and killed a number of people because he had no idea what he was doing. Because he was like given a privilege to be a neurosurgeon. Because you know, someone at some place just kept signing off on him. And and we talked on the last episode with Dr. Tolus, who's one of the probably one of the leading CT surgeons in the city, uh in the city, in the uh in Boston for sure, but also nationally, about deficiencies in training in the US program and and and kind of the difficulties they're facing in terms of uh kind of the headwinds they're uh you know, CT surgery is up against. So it's very, very complex. So, you know, um you know you know, I I heard a smart guy told me if your policy sounds nice and abstract, uh, but doesn't take into account my implementation challenges. Um so uh you know, I I I'm a little uh I'm a little skeptical that we are gonna be able to uh do this uh for some of these some of these, especially some of these very you know competitive uh residencies. And the other the other big problem, I think, adding in getting the getting the second order part of what the smart guy said was was the fact that uh well two things. One is what it what it does is it it maintains the I think too high bar that we have erected for US citizens to become doctors, right? I think we have a system that you know i i is somewhat broken in terms of the length of time and debt that it takes to become a physician, to say become a neurosurgeon. Um and uh and and and simply allowing imports of physicians does not actually give any impetus to try to fix that, to create real accelerated lines where you could take bright, bright people from Montana and you know, allow them to practice at some level in the US. And so that's that's one, I think. And then the second thing is maybe it's third order, but does it matter culturally if folks that are arriving are completely different from the areas that they're coming into? Meaning this is a little politically incorrect in some senses. But if you have if you have a deeply devout 90% Christian small town, are there second-third order effects of having folks that aren't culturally similar coming in there?
SPEAKER_01Careful, Anisha. You're about to say that babies being delivered by discordant race OBs are gonna have worse outcomes.
SPEAKER_00Right. Exactly, yeah.
SPEAKER_01Well I see the point though.
SPEAKER_03Yeah. On the first one, let's work on both, right? Your question was about like, aren't uh aren't the requirements too high for US as well. Yeah.
SPEAKER_00I mean, we we and and we but there's no there's no there's no impetus to fix that, Jared, as long as a hospital system can set up a residency program in a in a small town and they're gonna get paid, you know, a hundred one hundred to two hundred thousand dollars per resident from the federal government through GME Medicare. You know, GME Medicare is $45 billion that goes to train all residents. Like, is it our job to be, you know, so it's just too easy for these little residency programs to be like, all right, I'm just gonna stand up uh a program and get paid and now have cheap labor. That's not cheap labor, meaning it's not even cheap. It's like you're making money off of the residency program that you do have. And by the way, you're not necessarily providing the greatest training in that residency program, right? Because it's a smaller community program. These are the ones that frequently international med grads end up in. So there's lots of residency programs, Jared, in small community programs that there isn't a gastroneurologist on staff. So these residents are training at a place where there's zero gastroneurology, all right? They're training at a program that has zero rheumatologists there. They have no dermatology exposure. Um, and so they're essentially cheap labor, they're manning the hospitals. Uh, we have other people that can that can man hospitals and you know, do the work of inpatient, outpatient type of thing. Uh sorry, inpatient outpatient, do the do the work of inpatient hospitalist type of medicine is what I meant to say. Uh instead, it's being done by cheap labor from you know some uh other other country. And we're not providing a great training environment. And by the way, then those folks are going out into these communities. They frequently are culturally culturally very different. English is a second language, you know, they and just to be completely blunt about it, they may have voting patterns that are completely different from the community that they belong to. And again, uh you know, no one's no one's arguing no one should argue for sure that you know anyone within the United States should be able to travel, can't travel somewhere because they don't, they don't, they don't they don't match the the political demographics of that area, right? But uh but I mean what are those what are those how do you deal with the third order effects of of of folks from other countries coming in, right? So suppose suppose you have you know suppose 90% of the folks that are coming in from one country are communists and they will vote for far-left communists every single time, and they'll take the the money that they're getting from Medicare, Medicaid and stuff, and they will donate large sums of money to get the Communist Party erected in that in that little small town. We have control over that because they're not from from the US, but why should we be allowing that to come in from other places?
SPEAKER_03Okay, so we're a bit far afield from like foreign-trained physicians and uh and like we're right now we're we're into like regular old immigration uh fourth order effects.
SPEAKER_00But isn't it something to consider?
SPEAKER_03Yeah, well, okay, well, I mean, uh there's I mean there's a few things to to push back on. Like you know, just letting somebody into the country and giving them the ability to work doesn't necessarily uh give them civil rights, uh civil rights being like voting rights, the ability to like go and and influence an election and that sort of thing. I mean, at a certain point, I could I could you know maybe touch on a couple more things like that, but uh at a certain point I would just say like that's why we need the battle of ideas, and that's why we need to uh you know be promoting uh the ideas of of of markets and and and uh liberal tolerance and that sort of thing. Some of the things that you mentioned, like I I'm not sure that it's anybody's problem to to or anybody's yeah, like anybody's problem to fix. Like, like if you just if somebody comes over and they and they don't speak the language very well, well, what have they always done? They've they've either they assimilate, learn the language or they don't. You know, what's it it doesn't necessarily I mean they're they're now here, they're now interacting, they're part of the community. Did I have a right to have a community without them? I don't know about that. And like they're they're just they're they're now with us. And and and I don't I don't see that it changes too much. It can change the the look and feel of the world. I'll give you that. But like I I wouldn't say that we have um like a a right to uh uh to to hit pause on how things are right now and not have things change.
SPEAKER_00Well, we we were talking earlier about the how to have a different conversation about healthcare, right? Um we're talking about in the United States, we don't do a good job in terms of discussing rights and where they come from, right? The healthcare workforce and large force is is a one of the levers, one of the players in terms of how health policy is made, right? So uh again, you know, uh you have a bunch of folks, you know, 40 percent, uh is it 40% or something? There's a significant push portion of the um uh US medical force that is now you know not from the US, right? And they do not have a laissez-faire capitalistic, you know, uh you know, uh talking to them objective uh, you know, this is true of domestic citizens as well, but but are we just making the problem even worse um by yeah? So I'm not saying I'm not saying there's a right to I'm not saying we have a right to prevent that from happening, but you know, look, is that is that not a consideration if every single person that if the vast majority of of folks that come that come have a completely different value set and and here we're trying to move the population to healthcare is not a a positive right and talk about negative rights, I mean we're not we're never gonna get there if we if we if we keep if we don't if we don't think about this thing. It gets to this whole, you know, is the United States a a creedle nation? I we asked this to the to the last guest, or or is there some shared a shared value set that we need to value and we need to kind of protect or not? Or is it just you know you come here and if you believe in uh you know some basic superficial rights, then hey, you're an American.
SPEAKER_03Well, I I mean I'd love to think that we still do have a good basis of you know of a thought of of what uh what America is. I mean, I I'm not sure it's that unique of a problem, but like what you're describing. Like the people that come here are I'm not sure that they're that less likely, statistically, even if we're talking about that, to be receptive to a pro-market uh kind of message and and ideas. A lot of a lot of people who are like, I don't know, the either immigrants themselves or the sons or daughters of immigrants are more patriotic than than some other people that I know who who are from here, you know, stretching back many more generations than than the the comparative group. Yes, I I just uh quick quick um concrete. Okay. We've got uh we at the Center of Model for Health, we have a fellowship. So we've got 12 students coming in this summer who are gonna spend a couple weeks with us and we're gonna, you know, we're gonna do uh readings and and classic uh uh stuff. We're gonna have have a debate. All kinds all kinds of good talks and and lectures and everything. Um when I look down that that list of names, there are a lot of um there are a lot of names from how do you how do you even nicely say it? I don't know, but but non-European nations. There you go. Thank you. And so so that's awesome, right? And I mean that's great. And I don't um yeah, so I think that's what is that so. They're the ones that are seeking out and saying, hey, they filled out our application, did our little essay, and you know, and are eager to they're gonna come and and read Rand and uh and and you became and Hayek with us as as well as a bunch of like classic you know things in uh in in health policy. You know, we do the Avro paper and stuff. Um you know, and and they're the ones that are signing up for that that program. So I'm I'm impressed.
SPEAKER_00No, no, absolutely. So no, I was I was I I I um you know, I I I'm like I was born, I'm an immigrant. I was born in uh born in India. I came here when I was 10 uh to the lovely town of Pittsburgh. And uh it just it it just it it um every time I see some someone that's extremely far on the left that that comes from that comes from from India is Indian origin, I'm always I always like I always get a headache, you know. So but I know a lot of people who are very of course I mean you know uh I mean I can name a massive list, you know, National Review, uh Ovik Roy, uh you know, free op, you know, the list goes on and on. You know, the last guest we had on was uh was uh Pradeep Shankar, who's you know also writes for the National Review and is is is conservative and stuff. But the members of Congress, and you look at Pramila Jaipal and Rokhana and Sri Thanadhar and uh Raja Krishna Murthy, um like, oh man, I wish I wish we had we had a better representative showing of you know laissez-y faire objectivist uh folks. But you know, maybe with your help for the Center for Modern uh the Center for Modern Public Health's uh help, you know, we can foster this so that uh maybe maybe that first wave is maybe mostly one value set, but that second wave, you know, is now truly American.
SPEAKER_03We're we're individualists, right? So like it, you know, it's it's it's case by case basis.
SPEAKER_00So but is there is there s is there like individualist is it is there any so you think maintaining this type of individual s individualistic, you know, you're allowed to pursue whatever it is you want, right? You think that will that that that's a stable situation, meaning that that is not something that eventually leads to like how how do we promote a certain value set? Like like you're obviously promoting a certain value set. You're an objectivist, you know, you're you're a randist, you're John Galt is uh should be a hero that should be taught in uh in a fictional hero that should be taught in, you know, our the our entrepreneurs should be should be kind of uh uh raised up and not not not regarded as uh these billionaires and like no billionaire should exist type of thing. Uh how so your argument would be marketplace of ideas, that let's just make the case and you know, if we make the case and we lose, we make the case and we lose.
SPEAKER_03Well, I mean I'm not gonna force anybody to like that would be a contradiction for me to to adopt that sort of strategy, right? That makes that that makes no sense. You can't I'm not going to You don't want thought police? Whoa, whoa, whoa, whoa, whoa. Yeah, right. I'm not gonna uh you know adopt an evil means to to to try to bring about something that I think is a noble end. Uh, no, no.
SPEAKER_00When it comes to immigration, like in terms of who should become an American citizen, it doesn't matter how to does it matter what they profess. Like, you know, does it matter if they are you know whatever their value set is, it doesn't matter. Like if they just go through the regular process. Because right now the process to become an American doesn't necessarily mean you share the value set of the dominant culture that has existed for some time, though you know that's been shifting a while.
SPEAKER_03Yeah, not not necessarily. Although I've been to a couple of immigration, what do they call them, naturalization ceremonies? They are moving. I'll tell you.
SPEAKER_00It's amusing. Yeah.
SPEAKER_03Um No, but but to take your question, I mean uh I mean may again, and I'm not like an immigration special policy specialist, but um, you know, I think there could be some perfunctory checks at the border for I don't know, like if you're like obviously a a known terrorist or something, and if you're if you're you know actively contagious with something, et cetera. Maybe a couple of things like that could be defensible. But no, j generally not on like the the you know the the the thought kind of stuff. Uh yeah, I mean would it would it be great if uh if we were flooded by not you know as opposed to um you know like a very you know violent ideologies or something like that, and if we were instead flooded by you know very kind of pro-market and pro-freedom, you know, kind of people, sure. But I probably wouldn't try to write it out into and encode it into some policy and and and have that be a part of a check on a door. I think it's it's it's it's everybody's for those who want to make it their project, it's it's our project to uh try to spread good ideas and and spread values. I say start, you know, start close to home, you know, start with your family and your neighbors and your community, who people who you actually interact with. That's that's where you'll be more effective there. My advice for everybody is spend a little at least a little bit a little less time on Twitter and that sort of thing. You know, those are probably not the most important thing.
SPEAKER_00So we are we cannot reprise Joseph McCarthy or saying no thought, Felice. Don't root out the anti-communist. Okay. Uh well, this has been I'm sorry, just look at the time. I was like, my goodness, we've been talking for a while. I mean, this is super fun. So thank you so much. I've taken up way too much of your time. And Dr. uh no, he's gonna send me an invoice. I mean, God knows how much he bills people for per hour of his time. You can't.
SPEAKER_03So thank you for so much. This has been a lot of fun. I I've really enjoyed it and uh yeah. Fantastic.
SPEAKER_00I I don't know even I don't know if it's gonna be possible to link to all your amazing your great pieces that you have, but we're definitely on the show notes we'll link to uh uh some of your uh essays that we've kind of referenced uh in the in the show as well. So already thanks so much. So stay on. Thank you. Thank thanks again, Jared.