Richard Helppie's Common Bridge
The problems we have in the country are solvable, but not solvable the way we’re approaching them today, because of partisan politics. Richard Helppie, a successful entrepreneur and philanthropist seeks to find a place in the middle where common sense discussions can bridge the current great divide.
Richard Helppie's Common Bridge
Episode 299- Inside The Fight To Fix Health Care Financing. With Nate Kaufman
The real fight in U.S. healthcare isn’t between doctors and patients—it’s against a financing maze that raises premiums, hides quality, and rewards middlemen. We pull back the curtain on why ACA plans look the same yet cost more, how public underpayment pushes employer premiums up, and why political fixes often fail when crafted far from the bedside. With Nate Kaufman joining from the Healthcare Bridge, we tackle the hard trade‑offs behind subsidies, health savings accounts, site‑neutral payments, and the myth that consumers can “shop” their way through complex, high‑risk care.
We share a clear framework: protect access now, then rebuild incentives. That means a short‑term patch to avoid coverage gaps, targeted funding for primary and urgent needs, and raising Medicare and Medicaid rates toward actual costs to reduce hidden cost shifting. We also explain where HSAs can help—simple, predictable care—and where they break down—leukemia, cardiac surgery, and other cases where data is scarce and choices are high‑stakes. Along the way, we confront the Fortune‑50 scale intermediaries extracting value and explore how transparency and outcome‑based accountability can shift dollars back to care.
Looking forward, we outline a path to a simpler, fairer system: consolidate taxpayer‑funded coverage into a universal base, open drug benefits broadly with smart negotiation, and end tax preferences that prop up inefficient private plans. Most importantly, bring insiders—clinicians, operators, and contract negotiators—into the room with lawmakers so policy matches reality. If you’re ready to move past soundbites and into practical steps that protect patients today while building a stronger system tomorrow, this conversation is your roadmap.
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Welcome to season seven of the Common Bridge, hosted by Richard Helpie, a leading analyst, philanthropist, and entrepreneur. Now expanded with healthcare, education, finance, science, and world affairs bridges, the podcast now in its seventh season, with an audience of over seven million worldwide, explores issues in a fiercely nonpartisan way. Find us at the Common Bridge at Substack.com, YouTube, and wherever you listen to your favorite podcasts.
SPEAKER_03:Hello, welcome to this special edition of the Common Bridge and the Healthcare Bridge. This is a joint presentation of your host of the Common Bridge, Rich Helpie. And joining us from San Diego, my good friend and colleague, and the host of the Healthcare Bridge, Nate Kaufman.
SPEAKER_02:From uh the East Coast, so I'm a little bit uh blurry on it.
SPEAKER_03:So always clear about health care and controversy right now in the federal government about what to do with health care. I just want to set the stage. Look, on the demand side of healthcare, we've got many people that want wellness, they want diagnostics, and then they want to be treated. And then on the supply side, we have amazing healthcare systems that provide preventive care, that provide screening, and that also have great therapy. So in the middle, there is this disaster of the financing way that we do things in the United States. And as my good friend Nate says, the largest insurance company changes our CEO every four years. So, Nate, today the Democrats are saying we're not voting for anything that looks like a health savings account from the Republicans. The Republicans are saying we're not voting for anything that looks like a subsidy that would extend into the premium support for the Affordable Care Act, the Obamacare. How do we explain this to people and tell them what that fight's really about?
SPEAKER_02:The first way to explain it is I just came back from the East Coast. I spent five days with doctors, uh various specialties, trying to improve the care that's provided by a healthcare system. I was inside the healthcare system working. And the challenge that I see is the people outside the system who don't understand the nuances are amateurs. And so we have a bunch of amateurs with political agendas trying to fix the most complicated system on the planet. And um what they're trying to do actually is two things. They're trying to solve the Affordable Care Act issue, and they're trying to at the same time solve the complex issue of our system is in fact broken and we need to fix it. Well, you can't do that in first of all, I don't necessarily think we have the right people, but the second issue is you can't do that in three weeks. It's going to take a lot longer. So what we need is a patch.
SPEAKER_03:Yeah, exactly right. Yeah, the the yeah, the right kind of overhaul that we've talked about isn't possible in these three weeks. So under the Affordable Care Act, the idea was there would be these health care marketplaces, and that people would be able to go there, choose their own plan. Remember, you keep your doctor and save$2,500. But then they made this mistake of, well, we're going to design all of the plans and we're going to limit the margin that the health plan providers would be able to get. And so guess what? All the plans look alike. And the only way for the United Healthcares and Aetnes and Blue Crosses of the world can make more money is just to keep cranking the premiums up, not doing anything to provide us care. So during COVID, the Biden administration said, you know, we're going to increase the subsidies and we're going to extend them. They're due to expire in about three weeks. And the Democrats are saying, hey, let's just put more money in there. Am I framing that correctly, that definition of subsidy?
SPEAKER_02:Uh yeah, uh, there was all kinds of at one point the the health uh the government was going to help co-payments and deductibles um and not deal with the um premiums as much. But what happened was there was a shift, I think it was with Trump, but I'm not sure. And we went to premium subsidies, and the premiums are way too expensive, and they've increased like 100%, some ridiculous amount, and there's no controls over that, and there's no market, and the deductibles are high, and the co-payments are high. It is a mess, and it needs to be fixed, but it can't be fixed in three weeks. And again, it can't be fixed necessarily by the folks that are trying to fix it. Um, one of the things that I see on the web all the time are academics and uh policy experts and others and politicians coming up with these hypothetical models to fix it. And the problem is if you don't understand the nuances of our healthcare system, you're just gonna make things actually worse. So, and in some respects, Obamacare kind of did that. And so what we really need to do is focus on improving the system, but we need this patchwork, or there are gonna be people that are gonna suffer. They won't be able to afford health care, they're gonna show up in the emergency departments, and everybody's gonna suffer because when you need emergency care, it's gonna be clogged up with all these uh people that couldn't afford the premiums. So um what we need right now is a patch, and then what we need is people that understand the health system to actually start working together with the politicians to fix it.
SPEAKER_03:Yes, and I think you and I are together on the contours of a greater plan, which should be a uh consolidate all the taxpayer supported programs, and everybody gets that, every citizen, every green card holder. Let there be a private market above and beyond that, but also that would not be tax advantaged, that the health insurers would have to make a relevant product that actually added value. And you know, of course, in my book, it's also like let everybody get on Part D for drugs right now. But for this patch right now, so the Democrats are saying, yeah, yeah, the system's broken. We didn't save$2,500, the costs have run out of control because of all the mandates inside the plans. Let's throw more money at the problem, which isn't just kicking the can down the road. But to your point, is that what can we do besides kick the can down the road? The Republicans are coming back and saying, look, health savings accounts are the way to go. And just to set the table, that health savings account were a device designed to let people put money out of their paycheck like they would do a 401k. That money would be growing tax-free that could then be used for medical care. And if you didn't use it up, it'd be available for long-term care. Now, in theory, that sounds good, but what's been the practice? What do we know about HSAs right now, Nate?
SPEAKER_02:Well, we know is that HSAs don't work really well. They don't work well. I mean, again, this is the theory. There's this, there is a professor who's promoting, just give everybody, you know, fifteen thousand dollars and let them go buy health insurance. But this is an asymmetrical market. How are people gonna know what is good health insurance and what isn't? You know, one of my thoughts is uh if Medicare and Medicaid paid about 50% more than they're paying right now, we could say Medicare for all. Because at that point in time, uh Medicare would cover the cost. One of the biggest issues that people don't understand is uh state of Connecticut, Medicare covers 70 cents per dollar of cost. Medicaid about the same. So if two-thirds of your patients, you're losing 30 percent on them, uh what are you gonna do? And by the way, Emma says, Well, you just need to cut costs. And yes, there are abuses within health systems, but I just I negotiate contracts. The uh my hospital clients wouldn't have anesthesia if we didn't pay the anesthesiologist more. They wouldn't have radiologists. So, right now, what we need to do is just solve this problem and the immediate problem and then go from there. And don't listen to people who are not intimately knowledgeable about the inner workings of health systems. It's just a theory. You know, I don't know what the difference is between a theory and a hallucination, but I don't think it's much.
SPEAKER_03:It's not because it's neither one stands the test against reality. But anything that starts starving the healthcare insurers, I'm in favor of. So the notion that you're saying, look, we're gonna spend the taxpayer money anyway. And what the Democrats are proposing today is take the money, give it to the insurance companies by individual, and somehow magically that will come out in the end, they'll quit asking for more, which has happened, let's see, never. And the the but what you're proposing is look, we're just going to raise the reimbursement rates for Medicare and Medicaid, but I would also propose, concurrent with that, cut the tax-favor treatment of that employer-provided private plan. The providers will make money on Medicare and Medicaid or Medicare for all, and the United of the world won't have the taxpayer subsidizing them. So I think that would work. Now I want to come back to HSAs, though, but go ahead.
SPEAKER_02:Yeah, the other piece that the Republicans are saying, and I'm not political here, I'm just focusing on health care, is they're saying, well, let's move to site neutral, meaning that you will get paid, the hospitals will get paid the same rate from Medicare as an ambulatory surgery center for the same procedure. Now, that makes a lot of sense. Except, Rich, what do you call a Medicaid or no pay patient in an ambulatory surgery center? You don't have them. Okay, so why are commercial insurance, uh, is commercial insurance so expensive? To subsidize the underfunding of Medicare and Medicaid. It's a fundamental issue that needs to be addressed. And if you cut the Medicare reimbursement to hospitals to make it equivalent to the ASCs, you want you're gonna see what we're seeing in rural hospitals right now. Services close, hospitals close, access problems that you won't believe. And so, again, from my standpoint, we have amateurs working on a very complicated problem.
SPEAKER_03:Absolutely. Look, when you look at HSAs, and they've been around for a while. They didn't make it into Clinton care bill, they didn't make it into the Obamacare bill, and there's a lot of theories. It's that people won't spend their own money when they need to, that they that they won't do it. Other arguments are, you know, look, when we look at certain things like 529 plans for college education, there's not really good data that says people that wouldn't have saved for college did, but people that had means, they sure took advantage of the tax break. And that potentially that's uh it with the HSAs. There's a case that people don't know how to spend their own money, but that's the negative case, the pro case on health savings accounts. Let's say that we didn't get the subsidies, but people got a funded health savings account. So that would take away the notion that people didn't have the means to put money away. Number two, they could go buy services directly when they needed it, so they don't have to access their services. And if you watch the flow of things, if services are going to get paid for directly, that means that that private insurer is not going to pay it, which means that their claim experience is going to go down. And again, theoretically or hallucinatorily, the their premium should start uh walking its way down. But you know, at least with an HSA, people could pick their own doctor because it's cash.
SPEAKER_02:But see, that's the whole problem. The whole issue is picking your own doctor based on what? Okay. So the theory is if people have the money, they're going to become educated shoppers. So I'm a pretty educated shopper. I've mentioned this before. I have a friend who's got leukemia. Okay. How do I shop for that? The number one issue for leukemia is what's the mortality rate for a bone marrow transplant. Well, there's no data on that. You can't, you you've got they like call each place and beg them for that information, and some of them won't even give it to you. So, what are we shopping for? Remember, 10% of the population consumes 80% of the healthcare dollars. They are not shopping. So this whole notion of if you give people money that they're gonna shop, they don't have the information, they don't have the expertise. And when you're sick, you're going, you know, you're gonna try to find out where's the best place I can go to get healed. You're not gonna be shopping like you do for other products.
SPEAKER_03:Look, those are great points, but but but also if you took the average household income,$52,000, the people that are getting really slammed by the Affordable Care Act increase in premiums, and then one side of the aisle saying just let's throw more money at the subsidies and put this false economy in place. But think about giving that family$3,000,$1,500 for each of the parents. Now they've got$3,000 available, their child has an earache, you know, they don't have to say, what about the deductible? What about the copay? What if they need it, you know what? I've got$3,000, it's there for medical care. I'm gonna go get my child taken care of and just leave it outside the insurance system versus washing it through Aetna or Cigna or any of them and having them scrape profit off before the the doctor in the pharmacy gets paid. That's where an HSA could go. We you know, again, we've got to do something. And I understand I couldn't find anything on it today, but that there was a discharge uh petition. Thank you that out of the house that said, let's do both. Let's extend the subsidies and let's fund HSAs. And you know what? At this point, why not try everything until we can fix the problem?
SPEAKER_02:Well, I I sort of agree, but remember the deductible$7,000, it's not$3,000. And that family with$51,000 has to pay premium for catastrophic care at least. Uh and again, it it's very complicated. There's a thing called direct primary care where you can actually, it's like a health club, but it's for a primary care doctor. You pay$60 a month, and they actually do that. Uh unfortunately, they limit their capacity, so less people would have primary care doctors if we moved to direct DPC model.
SPEAKER_03:So And look the supply would come in, but let's not let's uh let's save that for another day. Anything else about subsidies versus HSAs that we get this out, and hopefully this is helping people understand the issue a little bit. Anything else that we want to wrap up with here?
SPEAKER_02:Yes, we got to deal with facts and not feelings and opinions. And again, it gets back to the healthcare bridge. Um the facts are from insiders, uh, people that actually deliver care and work with people that deliver care. And uh unfortunately, what we have is uh people that don't understand the business and don't understand the interrelationships pontificating about uh how to solve a very complicated problem.
SPEAKER_03:Amen. And I'll just uh close with that in the middle between the people that want the prevention, the diagnostics, the treatment, and the people that provide those services, there's a big, ugly system sucking money out of it that's not helping either side of that.
SPEAKER_02:Well, there's a bunch of middle people that are these lamp ray ills that aren't adding value, that are really sucking the dollars out that need to be put back into care delivery.
SPEAKER_03:Well, but they're on the Fortune 50. So, with that, um with my good friend, my colleague, and the host of the Healthcare Bridge, Nate Kaufman, this is your host, Rich. I'll be signing off on a special edition of the Common Bridge.
SPEAKER_01:Thank you for joining us on this episode of the Healthcare Bridge. We hope you gained valuable insights into how strategic and financial analysis can transform healthcare delivery. Remember, building stronger connections in our healthcare system is a collective effort, and we're honored to be part of that journey with you. Be sure to subscribe and stay tuned for more conversations that aim to bridge gaps and create a healthier future for all. You can find all your healthcare bridge episodes at the Common Bridge on Substack, YouTube, and your favorite podcast platform.