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Follow the Money! Understanding the Structural Incentives for Inequality in Health Care and Beyond

Learning Objectives
1. Explain how profiteering in health care incentivizes inequitable care and harms all patients
2. Describe the role health care professionals have in advancing equity
3. Identify opportunities to advance health equity in medicine through individual, institutional, and structural solutions
1.5 Credits CME

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Audio Transcript

Emily Cleveland Manchanda, MD, MPH: (0:02) Hello, and welcome to National Health Equity Grand Rounds. I'm Emily Cleveland-Manchanda, the Director for Social Justice Education at the American Medical Association and an emergency physician at Boston Medical Center.

(00:15) Today's event, Follow the Money, Understanding the Structural Incentives for Inequity in Healthcare and Beyond, is the second in the National Health Equity Grand Rounds series. These events have been developed by the Accreditation Council for Graduate Medical Education, the American Medical Association, the National Center for Interprofessional Practice and Education, and RespectAbility.

(00:40) The series serves as a platform for critical national conversations about complex topics in health care. In these events, we discuss root causes of present-day health inequities by tracing the social, economic, political, geographic, and environmental forces that shape opportunity for health in the United States. In each conversation, we also discuss opportunities for each of us to intervene as individuals within our institutions and collectively as part of a national movement to advance equity in health care. Next slide, please.

(01:16) We're grateful for each of our amplification collaborators who helped bring this series to you, each of whom is working to advance health equity in their context. Next slide.

(01:27) We'll begin with a land and labor acknowledgment that you see before you. We acknowledge that we are all living off the stolen ancestral lands of Indigenous peoples, which they have cared for since time immemorial. We acknowledge the extraction of brilliance, energy, and life for labor forced upon people of African descent for more than 400 years here. We celebrate the resilience and strength that all Indigenous people and descendants of Africa have shown in this country and worldwide. We carry our ancestors in us, and we are continually called to be better as we lead in this work.

(02:04) We also want to note that each of the speakers in the National Health Equity Grand Rounds series are invited to share their individual perspectives. The views they express are their own. In the interest of open and respectful dialogue, the series may include speakers whose views do not align with the official positions and policies of some or all the collaborating organizations that bring you this series. We invite you today to join us with an open heart and open mind. Next slide.

(02:33) Our learning objectives for today's session are as follows. We hope that after today, you'll be able to explain how profiteering and health care incentivizes inequitable care and harms all patients. We hope you'll also be able to describe the role that health care professionals have in advancing equity and be able to identify opportunities to advance health equity in medicine through individual, institutional, and structural solutions. None of our speakers have any disclosures today.

(03:03) Before we begin, just a few technical notes. You can submit questions using the Q&A feature to the right of your viewer, which also allows our event hosts to communicate directly with you. Questions will not be visible to others in the audience. If your stream seems blurry as you're viewing it, it may be because the video player is automatically changing the resolution based on your internet connection. You can adjust the resolution of the live stream by clicking the gear icon found at the bottom right of the video player and selecting a different quality.

(03:33) I now have the pleasure of introducing you to Dr Karthik Sivashankar. Karthik is the Vice President of Equitable Health Systems at the American Medical Association and a psychiatrist at Justice Resource Institute. Prior to his current role with the AMA, He served as the inaugural medical director in quality, safety and equity at Brigham and Women's Hospital, where he designed and led innovative work to leverage existing quality and safety practices to systematically make inequities visible and to address them as an integral part of quality health care delivery. Karthik, I'll turn it over to you.

Karthik Sivashanker, MD, MPH: (04:08) Thank you, Emily. So really excited to be here with you all today and thank you to all that tuned in and are tuning in. So in our first Grand Rounds, we spoke about the history of racism in medicine. And today we'll be talking about the role of money, profit and greed in health care. And this is no accident. Together, profiteering and racism are slowly killing all of us and are at the heart of the brokenness that we see in health care. And we've all seen these dire headlines warning about the potential collapse of the US health care system, about why health care services are in chaos everywhere, how hospitals are facing bankruptcy. There's a shortage of doctors and nurses and other health care providers who are burning out. We've dropped to 64th in life expectancy. And ultimately these root causes are killing some of us more than others differentially, but ultimately it's harming all of us.

(04:59) Our health care system is struggling by every major indicator, and it's ultimately limiting the full health potential of every single person in this country. But we do have the power, if we can come together to make change. And this means changing hearts, minds, narratives, and stories, the stories we tell ourselves and the stories we tell each other, but also the stories and narratives that have been very effectively deployed over years, really over centuries to keep us divided and collectively ineffective in manifesting the changes that would ultimately benefit all of us and those we love.

(05:32) So it's up to us right now to determine our collective destiny moving forward. And this can begin by having these types of challenging and necessary conversations like the one we're going to have today. So for today's theme, we're going to be discussing structural incentives for equity, both within the health care system, but also learning from other sectors. And that's why I'm really excited to open up today with our keynote speaker, Edgar Villanueva, an award-winning author, activist, and expert on issues of race, wealth, and philanthropy. Edgar is the principal of Decolonizing Wealth Project and Liberated Capital, and author of the best-selling book, Decolonizing Wealth. He advises a range of organizations, including national and global philanthropies, Fortune 500 companies and entertainment on social impact strategies to advance racial equity from within and through their investment strategies. Edgar holds degrees from the Gillings Global School of Public Health at the University of North Carolina, Chapel Hill. He's an enrolled member of the Lumbee tribe and resides in New York City. So with that, I'm going to turn it over to Edgar. Thank you for joining us today.

Edgar Villanueva: (06:33) Thank you, thank you. Good morning, good afternoon to everyone. It's an honor to be having this conversation with you today. And I want to acknowledge the possible discomfort that could come about as we're having this discussion. And that discomfort is actually an amazing opportunity for growth. I think if we are honest and we just, we get right to it with each other that we can really be inspired to think about ways to respond differently, both personally and professionally in this work. As I mentioned years ago, I did write a book called Decolonizing Wealth. And in this book, it's really me sharing my experience as a walking contradiction. I'm Native American, I grew up in a very white world. I grew up very impoverished, but yet I've worked, I find myself working in the places of wealth, redistributing resources. And so in a lot of ways, I've walked and held lots of contradictions in my life.

(07:29) And also, you know, working in a sector of philanthropy that is about caring for each other and taking care of each other and seeing how because of historic and systemic racism, that always was not the case. So in short, my work really is about the story of my own journey and my path to belonging and connection and healing. And I believe that for all of us, in order to achieve racial healing, we have to acknowledge our own contradictions, our own brokenness. And then we have to be able to diagnose where we are hurting as a health care sector as well. So today in my brief remarks, I'm going to talk about where we hurt and how we heal. And then, we'll all along the way and in the following discussions, talk about how money and resources are connected to that.

(08:20) So it may be counterintuitive for us, but when we think about the health care industry, it has evolved to mirror what I call colonial structures that reproduces hierarchy and ultimately harms people in our efforts to do good. What do I mean by colonial structures?

(08:41) Well, first, are we clear of what colonization is? Because colonization seems totally normal to many of us because the history books are full of it. And because to this day, many colonizing powers talk about colonization not with shame, but actually with pride in their accomplishments. It's really the strangest thing. You know, conquering is one thing. You travel to another place, you take their resources, you kill the people that get in your way, and then you go home with your spoils.

(09:13) But in colonization, you stick around, you occupy the land, and you force the existing indigenous people to become you. It's like a zombie invasion. Colonizers insist on taking over the bodies, the minds, and the souls of the colonized. And colonization begins as a conquest and exploitation motivated by greed and fear, justified by a claim to God-given superiority. Its mantra is divide and conquer, command and control, and above all, exploit. And so we are living in a nation whose entire economic system was built upon this idea of colonization, dividing and conquering, commanding and controlling, and above all, exploit.

(10:05) And so in the book, I coined this term called the colonizer virus. And you all know viruses way too well, especially on the other side of this pandemic. And we know how viruses can continue to grow and mutate. Well, this colonizer virus has infected every aspect of our being, every cell, including our culture and our mindsets. The colonizer virus inside our culture and institutions is especially dangerous. Our education system reflects the colonizer virus. So does our agriculture and food system. So does our foreign policy. So does our environmental policy, the field of design, we can go on and on.

(10:46) And the topic of today's session, the health care industry, we absolutely show symptoms of being infected with the colonizer virus. And that virus is fueled by greed for money and power. I want to break this down a little bit and just give you five examples of how the colonizer virus shows up in health care.

(11:08) The first is power dynamics. The health care sector is dominated by people who hold power and privilege, particularly those with white or male privilege. This power dynamic mirrors colonial structures and reinforces unequal power relationships between health care providers and patients.

(11:26) Second, a lack of access to care. People of color and other marginalized groups are underrepresented, and they are often excluded altogether from the health care sector and services. This limits their ability to access health care and creates disparities in health care delivery and outcomes.

(11:51) Third is the medicalization of bodies. The health care sector tends to view the body as a machine that can be fixed through medical interventions. This view ignores the social and cultural factors that impact health outcomes and reinforces a colonial mindset that only Western medicine is valid.

(11:51) Fourth is pathologizing difference. Obviously I don't work in health care, so I'm stumbling over some of the terms here. But the health care sector often pathologizes different, sorry, such as class, race, or gender by framing them as risk factors for poor health outcomes. By doing so, it reinforces colonial narratives that non-Western ways of living and being are inferior or unhealthy.

(12:47) And then finally, number five is a failure to address root causes. The health care sector often focuses on treating symptoms rather than addressing root causes of illness and disease. This reinforces colonial structures and ignores the social, political, and economic factors that contribute to poor health outcomes. So again, a major factor in not addressing these issues or diagnosing the colonizing virus at play here is money because we have prioritized money over people and are often unwilling to give up money or power in order to see a different reality.

(13:26) So health care is very similar to the philanthropic industry that I primarily work in. It's full of resources, full of power, but often our good intentions are overshadowed by our unwillingness to make change in the world. And often the idea that we know best, which again is a colonial dynamic. Some refer to this dynamic as white saviorism. Now, when I say white saviorism, this is not an attack on white people. Being a white savior is a mentality. It's kind of like a side effect of the colonizer virus, and it's possible for all of us to heal from it.

(14:04) So I just want to identify five ways in which the white savior mentality shows up in health care. The first is dominance of white health care providers. The health care industry, just like my own philanthropy, is predominantly white, and as a result, people of color are often treated as others. This dominant presence of white health care providers reinforces the idea that white people have the power to save patients of color.

(14:34) Second are paternalistic attitudes. Health care providers may adopt a paternalistic attitude of thinking that they know what's best for patients, particularly those from marginalized communities. This can result in providers making medical decisions without fully considering their patients' preferences or values.

(14:54) Third is tokenism. In an attempt to address health care disparities, health care organizations may hire a few people of color and then fail to provide them with the support and resources needed to succeed in their roles. This tokenism perpetuates stereotypes that people of color can't lead or make important decisions reinforcing the need for white saviors. Four, cultural insensitivity. Healthcare providers may not understand or dismiss cultural differences in practices and beliefs which can lead to miscommunication, misdiagnosis and failed treatment or interventions.

(15:34) And then a fifth example is medical gaslighting. People of color, particularly women, have characterized their experiences of not being listened to by medical professionals as medical gaslighting. Medical gaslighting is when a health care provider dismisses or downplays a patient's reports of symptoms and health care concerns. Instead of listening to the patient, the provider tells the patient that their concerns are not significant or have psychological roots. So this white savior mentality is pervasive in health care and it contributes to disparities and inequities in health care access, delivery, and outcomes for people of color.

(16:17) So how do we heal from this colonizer virus? To address these issues, you, people in this sector, leaders, must prioritize equity, representation, acknowledging the role of social and cultural factors in health outcomes, and treating the root causes of illness and disease. And we must prioritize people over profits and be willing to make the investments necessary to address the historical and systemic racism that has been in place that continues the cycle of unhealthy outcomes for communities of color.

(16:56) I talk about medicine a lot, a way to cure this virus. And at first, when I say medicine to this particular audience, you may think of something that's used to treat or cure disease, often a human-made drug or sometimes an herb. In Native American traditions like mine, however, medicine is a way of achieving balance. An indigenous medicine person doesn't just heal illnesses. He or she can restore harmony or establish a state of being like peacefulness. Medicine people live and practice among the people. Access to them is constant and unrestricted. And the practice of medicine is not just limited to the hands of medicine people. Everyone is welcome to participate. Engaging with medicine is a part of the experience of daily life. Traditionally, indigenous people don't wait to be out of balance before they turn to medicine. In the indigenous worldview, many kinds of things can be medicine. a place, a word, a stone, an animal, a natural phenomenon, a dream, a life event like a coffee date with a friend, or even something that seems bad in the moment like the loss of a job.

(18:15) Have you ever looked back at your life and thought, that was the best thing that could have ever happened to me? That was medicine. In order for something or someone to serve as medicine, it only needs to be filled with or granted a kind of mystical or spiritual power. Anyone can find and use medicine just by allowing your intuition and feelings to determine whether something can serve as medicine. You listen for its sacred power, you don't force it. In my culture, they say that you don't choose the medicine, the medicine chooses you.

(18:51) So I want to ask you today: what is your medicine? In other words, what is your calling, your unique contribution to the healing that is needed for this industry. For me, working in philanthropy with money, I've learned that although the accumulation of wealth is steeped in trauma in this country, money can be used as a tool of love, to facilitate relationships, to help us thrive, rather than to hurt us and divide us. If it is used for a sacred, life-giving, restorative purpose. It can be medicine. When we move money to where the hurt is the worst, it can be a form of medicine. And we know that the hurt is the worst in communities of color. So we all must understand how to use our voice, our leadership, our influence to help heal, and be self aware of the potential to harm. That is medicine. This is the first step of what I think of as decolonization, and I'll unpack that word in just a moment. As healers, we must understand that the hundreds of years of colonization and oppression on this land, the taking of resources, the taking of wealth, the taking of land has resulted in deep pervasive trauma.

(20:15) How do we decolonize or begin to address this? Now, remember the mantra of colonization is divide and conquer, command and control, and above all, exploit. So you must find, first, find an acceptor calling, your medicine, and commit to be part of the collective healing process. We can't ignore history or our responsibility to repair. The hundreds of years of colonization that happened long ago and as recent as yesterday violates us and leaves us traumatized. And in fact, it has this effect on us whether we were the colonizer or the colonized.

(20:58) For me, the best way to understand decolonization is that it is the process of healing from trauma. It's acknowledging that there is a history before us that has led to so much trauma in communities and committing to a process of healing from that trauma because we cannot undo what has been done. Colonization violates us and leaves us traumatized. And what can we do about it? What we can do is focus on stopping the cycles of abuse, healing ourselves in order to expand our possibilities for the future. This means that our interdependence is inescapable. And so we might as well acknowledge each other's trauma and engage in healing together.

(21:44) So decolonizing is a mind shift. It's almost as if every day we have a pill in our mouth when we wake up. And that pill is the pill of white supremacy thinking, is the way things have always been. It's easy just to swallow the pill and move on with our day. But what we can do is choose to spit that out and say, no, I'm not going to do what's always been done. I'm going to commit to shifting my mind and being a part of something greater, a part of healing. So there are five, I will leave you with this, five specific actions that you can take to help heal the colonizer virus. The first is to acknowledge the role of colonization in health care.

(22:27) Health care, like all institutions, has a history shaped by colonialism. Providers can decolonize health care by taking the time to learn about the history and acknowledging the ways that colonialism has impacted their professions. Second is to prioritize cultural humility. Healthcare providers should prioritize cultural humility by recognizing that they do not always know what's best for every patient. They should approach each patient with openness and a willingness to learn about their experiences and preferences.

(23:02) Third is that we must be mindful of intersectionality. To decolonize health care providers need to be mindful of this, which means understanding how multiple identities such as race, gender, sexuality, can impact a person's health and experiences with health care. Providers seem to be mindful of their biases and adopt a more holistic approach to treatment. Four is to focus on community-based solutions. To decolonize health care, providers should prioritize community-based solutions, such as engaging with community health workers, faith communities, or partnering with community organizations to address health care disparities. These solutions can help to build trust between health care providers and marginalized communities.

(23:49) And lastly, we can develop a reparative approach which means providers can adopt a reparative approach to health care, which acknowledges that health care disparities are a result of historical oppression and structural racism. A focus on reparative justice means that we are looking at the past and working to make amends for the past. So I'm talking about reparations here. It's understanding that lots of oppression has happened over the last 400 years to people of color on this land. And it is up to all of us to address that truth, those facts, and that history, and think about how we as an industry can work to address that. Part of this work is understanding how this industry in itself is making money off of inequality and thinking about how we can support and provide care very differently.

(24:47) Honestly, I don't think that any black or indigenous person should even have to pay for mental health services given the history of oppression on our communities in this country. And so I'll conclude here just with this word. A relative used to say this to me often, that we must walk backwards into the future. That means that we get to a better future, to a better place by first looking back, you know, diagnosing and fully understanding how we got to this place, where we have prioritized profits and money over people, how we have accepted inequality as the status quo. Healing requires understanding how we got here. It also requires a collective responsibility, accepting that collective responsibility to heal this system. Because of all my relations, all of our suffering is mutual, all of our thriving is mutual, and all of our healing is mutual. Thank you.

Sivashanker: (25:52) Thank you so much, Edgar. We're going to now open this up to a full discussion. And so I'm going to start by just introducing our other panelists who will be in conversation with you. and thank you for setting up the conversation today.

(26:05) So I'll start with Dr Linda Rae Murray. So really excited to have Linda here who has spent her career serving the medically underserved. She has worked in a variety of settings, including practicing occupational medicine at a workers clinic in Canada, residency director for occupational medicine at Meharry Medical College, bureau chief for the Chicago Department of Health under Mayor Harold Washington, the first black mayor of Chicago. In 2011, she served as president of the American Public Health Association. And today she serves as an honorary attending of Cook County Health and an adjunct assistant professor at the University of Illinois School of Public Health. Dr Murray is devoting the rest of her career to bringing an enthusiastic, sorry, to being an enthusiastic full-time troublemaker.

(26:51) Dr Don Berwick is one of the country's leading scholars, teachers, and advocates in the world for the continual improvement of health care systems, a huge leader in quality and safety, a pediatrician, longstanding member of the faculty of Harvard Medical School, founded and led the Institute for Healthcare Improvement. And now that organization is a global leading nonprofit in the field of quality and safety. He was appointed by President Obama as administrator of the Centers for Medicare and Medicaid Services, which he served in 2010 and 2011. He's counseled governments, clinical leaders, and executives in dozens of nations. He recently wrote an important piece, "Salve Lucrum, the Existential Threat of Greed in US Healthcare." It's gotten a lot of attention and is an informative piece for this conversation.

(27:40) And then finally, last but not least, Noam Levy. Noam is a Washington DC based senior correspondent for Kaiser Family Foundation Health News, where he's currently producing "Diagnosis Debt." It's a multi-part series on medical debt in the US, in collaboration with NPR and CBS News. Noam joined Kaiser Health News in 2021 after 17 years at the Los Angeles Times. The last 12 is a Papers National Healthcare Reporter based in Washington. He's covered many different health care issues in more than three dozen states in the US and across four continents.

(28:17) So I'm going to begin with a more pointed question to each of you, and then we can open it up from there, really looking just for a free-flowing organic conversation here. And I want to offer to our panelists, if anything that Edgar said is resonating with you in particular that you want to speak to, feel free to go off the question I'm asking, but we're going to open up with Linda. So Linda, either any initial reflections based on what Edgar shared, the pointed question to you would be, what is the role of government and the role of government public health in providing health to people and guaranteeing the right to health care.

Linda Rae Murray, MD, FACP: (29:00) I think the most important thing that Edgar in his talk today and his book is really trying to explain to people what colonialism is. And so I really value that. And I think that leads us to an answer to your question about what's the role of government. If we believe, and I certainly do as a physician, if we understand and believe that the health of all of us as individuals and certainly the health of our communities is not based simply on our individual isolated actions, but it's really based on how we structure the society around us in its words, how we're connected with everything else that's going on.

If we understand that, then how can we possibly have health without a healthy government and without a healthy quote unquote public? The government right now, it doesn't do a good job of it, is the mechanism that we have as broken as it is to express the will of all of us collectively. And so in my mind, you really can't have a good health care system if you don't have a government that's paying attention to how people are reading and whether they're reading, whether people have parks and time to go to the parks, whether people have safe jobs, whether people have a healthy, nutritious food stream. All of those things are far more critical to my health and your health than what antihypertensive drug I might prescribe tomorrow.

Sivashanker: (30:29) Thank you, Linda. We're going to just keep this going around in a circle. Don, I'd like to ask you an initial opening question. You've spoken out recently about the need to eradicate profiteering from health care. How do you define profiteering in health Can you give some examples in the industry today that you see as particularly problematic in terms of harming patients, health care providers, society at large?

Don Berwick, MD, MPP, FRCP (30:53) Thanks a lot for having me, Karthik, and for the question. In my paper, Solve Lucrum in JAMA a couple months ago, I assert that there's really no component of the health care industry that isn't trying and usually succeeding in garnering excessive profit, profiteering. Insurers, for example, are extracting tremendous transaction costs out of very little value added activity.

(31:18) My colleague, Rick Kronick, estimates that in Medicare Advantage, the privatized portion of Medicare in the next eight years, insurers will bleed $600 billion out of the public treasury into their own pockets and the pockets of shareholders largely. In the pharmaceutical industry, high prices, extortionate prices have received a lot of attention and continue relatively unabated. Hospitals are reacting to the ambient conditions by consolidating and raising their own prices, especially powerful academic and tertiary centers, often to the disadvantage of community-based hospitals. And clinicians themselves, although they're trying to earn an income as anyone would, some of them are taking advantage of the situation to earn excessive income. All of this is money taken out of other uses, distorted, confiscated from other uses. Since about half of our care is paid for by government, that means that money going into the hands of people simply raising prices at no added value, that money's coming out of schools and roads and a lot of the kind of investments that Edgar was talking about.

(32:31) And on the commercial side, since about half of our payment comes from companies, employers, that's money that's denied to workers, could be in their pockets for compensation. It's denied to the companies for competitive uses in a global marketplace. So it's really sub-optimization of the wellbeing of a few on behalf of a many. I have not thought before Edgar's talk about colonization itself being greed-driven, but, you know, we, as human beings, we seek to accumulate more and we need government. We need each other to regulate those impulses so that we can be fair to each other and preserve resources where they're needed. Right now in our country, we are not doing that. And a lot of people are playing the pain and price, and especially the disadvantaged groups that Edgar has been talking about.

Sivashanker: (33:25) Thank you. Noel, I'm going to turn this over to you now. You've done a lot of important reporting on the topic of debt and health care and profiteering. And just want to really give you an open-ended question to speak to anything that was particularly salient as it relates to what Edgar has shared or others.

Noam Levey: (33:44) Thank you. Thanks for the question and thanks for having me. Well, I can only sort of, I think, underscore some of the points that Edgar and Don and Linda made in our reporting on the impact that this sort of mindset, I think that Edgar and Don and Linda described, the impact that that's having on patients. I mean, what we've found particularly from a financial point of view is that the downstream effect of a value system that prioritizes profits and power over patient wellbeing is that the system is now essentially producing debt on a industrial scale.

(34:29) We found that 100 million people in this country now have some kind of health care debt and more have been in debt at some point in recent years. And there's no question our data and other research has shown that that burden falls most acutely on the most vulnerable communities. Black Americans are twice as likely to have this kind of debt. They are twice as likely to have been turned away from medical care because they owe money. And so clearly a system that sort of I think at least rhetorically claims to be taking care of people is doing quite the opposite when it comes to the impact that it's having on people's financial security.

Sivashanker: (35:21) So let's talk about the system. We've used the word system a lot. And I'm thinking of this phrase, we've heard it in many different places in different ways, but the system is designed to create the outcomes that it gets, right? It's almost perfectly designed that way. It's an embedded feature. And so can, maybe I'll send it back to you, Edgar. How is profit, and if you'd like to take that on as well, racism in that intersection, how is that an embedded feature of health care and the system today? And why does it make it so difficult to tackle?

Villanueva: (35:57) Yeah, I love that question. You know, I often say that the system is people and people are the system because it's easy to think of the system as this thing over there, operating outside of human influence and control. I also think about, you know, it's kind of hard 'cause sometimes we think about how inequality, we're like, where's the dark, smoky room where someone just came up with all of this bad stuff, right? We want to find those guys, right?

(36:26) But the truth is that poverty as it exists is the product of public policy and it is the product of theft that has been facilitated by white supremacy. And so I think that we have to acknowledge that there have been very intentional public policies put in place historically, and they have been systematic to continue to keep things the way they are and continue to contribute to this widening gap of wealth between what is called the race wealth gap. And of course, we know that income is just a huge driver on the impacts of wealth or health, I should say. We also know that when we think about poverty being the product of public policy, it is the product of theft.

(37:14) And this is sort of a very traumatic oppression that continues to be enacted upon people of color, Black and Indigenous folks in this country, that even when we participate in our economic system and follow the rules, and we begin to build wealth, that wealth has been obliterated or taken away from us. And so there's this ongoing extraction that seems to take place that contributes to this mindset that is just so hard to get ahead of. And so I think health care has a very unique role to play in beginning to dismantle that, because across all the industries that I work with, as many challenges we have here in this particular industry, we do see and understand the connection between place often and other outside factors on health outcomes that we can begin to address.

(37:14) But we have to kind of take some responsibility. I think that physicians especially are often trained from a very individual kind of point of view, right? And it's like a patient to patient type of relationship but we have to all take responsibility for this system that isn't play and like interrogate how can one person begin to chip away at that and that collectively through our networks and associations begin to build power to make changes in this country. But we are, you know, it's very hard, honestly, and it is messy work. And it comes at the cost of losing power and losing resources, especially, right? And even like reputational, you know, credibility that we may have, and we want to really turn this thing around and do something different.

Murray: (39:02) You know, Edgar talks about colonialism, which I think is important. That's a specific kind of form of government and ruling over people that has a historical time period. We shouldn't be afraid to talk about the other C word here, capitalism. And we shouldn't be afraid, certainly as physicians, to understand that, especially in the early stages of capitalism—Du Bois talked about this and Cedric Robinson refined it—racial capitalism. What does that mean?

(39:32) That means that racism and capitalism grow up together. They're intertwined. They justify the expropriation of land from indigenous people, not just here in North America, but around the world. This notion that a difference must mean hierarchy. That is, that if you and I have different color of skin or different kinds of hair or different statures, one of us must be better than the other. You know, that's a deeply seated Western sort of philosophical view of the world that I think causes trouble. And I think it's important to use the word racial capitalism and to think about it in those terms, because certainly in America, colonialism, formal colonialism, ended centuries ago. But racial capitalism is alive and well.

(40:19) That's what I think—that's what I interpret Edgar to mean when he talks about the colonialism virus. It is an ever-evolving sickness, if you will. And it is a cause for major death and suffering throughout the world. As physicians, and more importantly, all health care workers, as we're supposed to be dedicated to improving the health of patients that we're privileged to serve, to join them in the process of trying to heal, we can't really do that if we're not willing to really explore what it means to talk about capitalism.

(40:54) Why should we say that someone can make money off of people healing? I want to challenge that very notion. That's the notion of excess profits. I'm against those, but why should that be? And so I think that if we, in fact, understand this wealth that's created, as Edgar says, foundations are representing twice-stolen wealth. If we, in fact, had a taxing system that was appropriate and fair and equitable, if we understood our history, we could set up structures in a society that would make it easier for people to stay healthy. It's very hard today, anywhere in the world, but certainly in America to stay healthy.

Sivashanker: (41:39) One of the forms of structure that perpetuates what Edgar and Linda are talking about is it has to do with power in government. Why would a smart country that needs resources to solve some of the problems that Linda's just referring to like the problem of being healthy, Why would a smart country allow this distortion of the flow of money in the health care world? Why would we allow drug companies to make and patent drugs at prices that almost no one can afford? Why would we allow insurance companies to take transaction costs that don't add value at the hundreds of billions? Why would we stand by while this kind of confiscation is going on? Well, the answer is because the only way we could fight it right now is through government action.

(42:33) But when wealth determines political power, which it does in the era of Citizens United, then government itself is disabled from putting in the tamping forces, the controlling forces that would change some of these behaviors. So we've got it, we've just got it set up wrong. And worse than that, as Linda was saying, I think the public has been sold a bill of goods that somehow markets will solve it. That if we set up a for-profit system and proper market forces, that it'll be self-healing. That's manifestly not true. We've been talking about that for 50 years and health care does not, in an idea, cannot function as a market, certainly not in pursuit of the kind of equity that we're talking about. We have to fix the distribution of power in government And that is a major battle ahead.

Murray: (43:27) Well, it's a battle we've had before. I mean, you know, the indigenous people of this North American continent would not exist if the market had had its way, but they're still here alive and well. I would still be picking cotton somewhere if in fact it wasn't possible for people to come together and change these things. We've done it before in our history. Unfortunately, we appear to be doing the same thing over and over again. But it is possible because these are systems that were created by human beings and they can be dismantled and rearranged by human beings.

(44:00) And I think the role that American medicine, organized medicine has to use our privilege and wealth and power to talk about this. Why aren't we insisting, every American health care worker should insist that we guarantee medical care, only a small part of health care. Medical care is a basic human right. And we have the power to do that in this country. We certainly have the resources to do that in this country. Some countries of the world may have trouble doing that. So why isn't that the baseline for any American physician? I think for many, many of us, it is the baseline. We're just afraid that we've psyched ourselves into thinking we can't do it.

Sivashanker: (44:44) I want to stay on this idea for just a moment about why do we allow this to happen? It sounds like we're allowing a profiteering or a profit at the expense of our bodies. Extraction is a word you've used, Edgar. But why are we allowing that to happen? And I think this is getting at that idea of identity and core identity. So we're having conversations and the moment we start talking about something like capitalism, there's a certain sector of folks who are listening who are now in a fight or flight mode. They, you know, their limbic response, They've been triggered to react to that and defend against that, 'cause it goes against the worldview that they've been shared, taught, integrated.

(45:27) And so the question then becomes, how do we actually talk about this in a way that all of us can actually hear? Because while the extraction's happening on every single one of our bodies, it's happening differentially on more on some, it's still hurting all of us. It seems like there's something there, and it may be, Noam, I'd be curious to hear from your perspective as being in that world about narratives and stories, and what's the challenge there in just communicating about these things?

Levey: (45:58) Well, I think, I mean, maybe I can tell, use an example about the challenge of, I think, communicating about this. And I think in some sense, it's particular to health care. So if we accept for a moment, the fact that the accumulation of market power by hospitals has a distorting effect on the overall and an inflationary effect on the overall costs of the health care that all of us are paying. And we accept sort of in abstract that that's bad. But if one goes to tell the story of why that is bad, and one goes to a suburb of a large American city that the local hospital has been gobbled up by the big medical system there. What you'll see oftentimes is you'll go to this community hospital and you'll see that there's a brand new big fountain in the lobby and there's a big glass tower that's been built behind it where now there are private rooms for everybody who's there, every patient who's there. It becomes very difficult to hold that up as an example of how this phenomenon that I just described is somehow bad. And if you go and you look at as the opponents of sort of countering this system that we have, we'll do, if you go and you go across to the UK, for example, and you go to a hospital in the National Health Service in London, and you see that in some rooms there are eight patients to a room still, you deal with this problem that we sort of have an expectation of mythology, I think around what health care should look like without sort of necessarily connecting it to the prices and the costs and the downstream effects, which Edgar and Linda and Don have articulated so eloquently. And I think that is fundamentally the challenge to dealing with this phenomenon and telling the story.

Sivashanker: (48:09) Reactions?

Berwick: (48:11) Well, it's harder to mobilize political will for collective good than for an individual interest. You know, the CEO of our largest insurance company, United, is alleged to make somewhere between 20 and $30 million a year in the past couple of years. I find that outrageous, that in a country struggling for finding ways to support its health care workforce, that kind of obfuscation can occur.

(48:46) The same goes for some of the hospital pricing gains. A friend of mine sent me a bill from a New York teaching hospital for one of his friends immunization of two kids for yellow fever vaccine. And the bill said $2,400 for vaccination. Now that's not really what anyone got paid in the end, but this is a very kind of seething loss of control of basics. And I think it has to do with social contract. I think anyone looking at this, certainly from another country would say, no, no, you can't, what are you doing? And they'd put a stop to it, but we are so fragmented in our collective voice that these individual interests dominate. And as I said earlier, they are connected to power in government. I love Linda's point that this is sometimes gets reversed.

(49:40) And Linda, I'm with you. We'll be there with you in whatever street we can find to start to say no. But we've had trouble mobilizing the collective no. I'll say one other thing that may be controversial in this group, which is I would say most interests in America stand to gain from a health care system under better control than ours. Not just the populations that Linda and Edgar are talking about, but also businesses, for example. the largest payers or businesses, the labor unions, anyone interested in any other civic form of engagement is losing money to health care. So I think the latent coalition is there. We just have not found the leadership of the platform to pull together that political voice.

Sivashanker: (50:29) Linda, any reaction to that?

Murray: (50:31) I agree with that. And I think that's true. And I think the real problem we have is that it's not that people don't want high quality health care. The problem is that the people with power in this country don't want to give up power. Not just the foundations, but the corporations. They don't want to pay the taxes that they ought to pay. Because once they pay taxes, then how the health care system is organized, how our education system is organized, how other social things that we organize, they don't have the same kind of control that they have if they don't pay taxes. And I think that's the critical thing. We haven't really answered the question of what does it mean to have democracy? How do you make democracy alive and well that respects people, et cetera? And most Americans, we're not very good at that. We have a very short notion of historical time and we have a very narrow blindfolded notion of ways to handle democracy. We have an odd democracy. It's not even a parliamentary system, which is still the dominant system in the Western world. So I think we really have to begin to grapple with things that may not appear to be directly about health care if we're going to understand how to fix the medical care system.

Berwick: (51:44) And can I just add one other thing to that point, which is I would want the guilds, the medical establishment, our colleagues to rise up on this. They have not. I haven't recently checked the American Medical Association's political action website, but I did last year, and the number one and number two achievement, it credited itself, the American Medical Association was with number one, protecting the income of physicians, and number two is preventing expansion of scope of practice of non-physician professionals. Number one, number two, in a country with this kind of trouble, I expect more of our professions.

Sivashanker: (52:22) Anyone else want to speak to that? Perhaps me, but I want to give you all a chance to voice anything around that comment. What can we do and what's the role of professional societies and organized medicine at large?

Levey: (52:43) Well, I'm not a physician, so I don't want to prescribe anything for any of organized medicine, but I'll share an observation, which is that, and I told this to Don recently, that one of the reactions to the reporting that we've done about this incredible suffering that patients are experiencing as a result of getting these kinds of bills that are literally driving people from their homes, literally forcing them to drain their savings accounts, to cut back on food, in some cases, to be unable to get Christmas presents for their children. One of the more disheartening reactions that we got from organized health care in general was, I would say, a pass the buck kind of reaction.

(53:31) And I think this goes to hospitals blaming insurance companies, insurance companies blaming hospitals, doctors blaming everybody, everybody blaming drug companies and PBMs, and a sort of disheartening lack of, I think self-reflection by health care writ large and unwillingness, I guess, to sort of look in the mirror and say, what is our mission? Why are we running these huge hospitals? Why are we developing drugs? Why are we seeing patients? I haven't detected a lot of that, but I have detected a lot of, it's not my fault, Look at how much I'm suffering. How dare you question what we're doing? Look at the guy down the street.

Berwick: (54:23) Noam, can I just ask you as a great communicator, and I really mean that, do you believe that if the professional community of this country, physicians and nurses especially, but not only, were somehow to find the voice to say, "Stop, this cannot go on, we will lead in that, but greed, excess, confiscation, disadvantage of consumers and especially people of low income has got to stop in this country that that could catalyze public momentum or is that naive?

Levey: (54:55) I don't think it's naive. I think it's probably necessary, but not sufficient. I mean, unfortunately, as you all probably know far better than I do, the locus of power within the health care system over the last several generations, I think it shifted away from physicians and to the well remunerated CEOs of hospital systems and drug companies and health insurance. And I covered the debate over the Affordable Care Act in 2009 and 2010. And despite the fact that the AMA and the other medical societies were actually quite vocal in support of that law, they couldn't move a single Republican vote on Capitol Hill, nor were they successful for the most part in state legislatures around the country. So I think it would be nice. I don't know whether it would be sufficient.

Murray: (55:53) But I think organized medicine and nursing have moved to support universal care. I don't think physicians are particularly good at understanding how to make political change, But if you look carefully, most of our larger organizations, the internists, the pediatricians, have really adopted positions that very much are in support of universal medical care. What's even more disturbing to me is the fact that we haven't collectively understood that medical care, while it's the most expensive part of what we do as healers, it's not the most important part.

(56:28) And so we've totally neglected and continue to neglect our public health infrastructure. And just as importantly, we neglect our broad social safety debt and services. But I think you're right, Don, that if people understood that these changes not only help the most marginalized groups, but also helps everyone up the chain, we really have a stair-step process. Maybe Bill Gates is OK, and he doesn't have to worry about his medical bills, but there are very, very few people in that high echelon that don't have to worry about what happens and their ability to take care of themselves and their families. So I think we just have to be willing to speak up and understand that there's a connection.

(57:11) And I'm not a member of the AMA for historic reasons, but I will tell you one of the truly shocking things that happened in my lifetime, two things that I never thought I would see. In 2008, some of you may remember, we actually elected a Black president in this country, which was truly shocking to me and certainly my parents' generation. The second, probably more shocking thing, was that the AMA apologized to Black physicians and the Black community for causing harm, which I still find an astounding thought. I still haven't joined, but the fact that the AMA was able to do that, and the fact that it's now putting on programs like this gives me some hope that if even the AMA can be moved to begin to speak out in a more appropriate way.

(57:56) And it's not a question of lobbying these people in Congress on inches to move. We really need to build a movement outside of simply lobbying the people that have elected positions to replace them with people who represent what that movement means, that represent what the people really want to see happen in this country for health. No one wants to pay an absurd amount of money for insulin, and most Americans don't agree with that. We really have to use our skills to find a way to join our strength as experts, excuse the term, in the area of healing with other people who are experts in so many other areas to really organize the political power that we need to have reasonable gun control. Well, actually, I want unreasonable gun control, but to have gun control to have the things we need to be healthy.

Villanueva: (58:51) I'll just add my voice to that. I get excited when we talk about apologies and truth reconciliation. I do my experience of working across many sectors right now is that we are experiencing an era of repair in this country. And we have big institutions like the AMA stepping forward to acknowledge its past and make apologies and make commitments to do different and not harm in the future. And to hold spaces like this, I think it's really critical. We're seeing across the country, more than 90 universities engaged in processes of truth and reconciliation. We're seeing reparations campaigns at the local, state and national level growing in speed. And even legislation has been brought forward to have a federal process of truth and reconciliation for indigenous and Native American folks in this country.

(59:43) So, you know, talk can be cheap as folks say, but I do think it's really important to hold space like this and conversations like this to talk about what's broken and how we heal. And our country is under attack when it comes to history and textbooks and what we can talk about and discuss. And I think that's a really strategic attempt to sweep things under the rug so that those feelings of individualism and racism can continue to fester. And so the only way forward is to kind of rip that band aid off and grieve our past and come together to think about what we can do differently in the future.

(1:00:23) So thank you for that, Linda. Sounds like I'm hearing we need a movement and I'm not sure that physicians or health care providers are really trained in that. Can someone speak to that? 'Cause that's a whole different conversation and skillset. We're trained to do, you know, to deliver health care services and to diagnose and give medicine, but advocating and, you know, policy, these aren't things that physicians and other providers are typically well-steeped in. And it sounds like that's maybe what's needed for us to see larger change. So I want to see what your reflections are there.

Murray: (1:01:08) If we're not trying to be saviors, in Edgar's words, then we have some hope. Because I'm now retired from providing clinical care, but the real joy to me over my career of practicing with people in my neighborhood to try to help them heal, that's a real joy. And that becomes very difficult in today's world when you have to, and I always worked in the public sector, So it was a little easier, but where you have to worry about what insurance company will pay for what and all these other regulations that have nothing to do with the interaction between health care workers and the communities that we're privileged to serve.

(01:01:52) So really, if we don't think about this as we need to save this community or we need to advocate for someone else, we are really advocating for what we love. What most physicians, there's some exceptions, but what most physicians and nurses and dentists and people that I know in the healing fields, they love the joy of working with other human beings and trying to make things better. And so to the extent that we can organize a movement, that is something that we're doing not just for our quote patients, but for ourselves as health professionals. And I think if we have that shift in attitude, that that will get more physicians not to be frightened by speaking up. We certainly know how to talk and we know how to organize, know how to run meetings. There are a lot of skills that we need in a movement that positions are well-versed in. We may have to learn how to listen better and shut up and let other people take leadership, but that may take a little practice.

(1:02:49) But I think that if we appeal to what is the best nature of why most of us went into the healing fields, that we will find the organizational strength that we need. It's not going to happen overnight, but to move our forces to at least not oppose these changes and hopefully to add some strength to the movements we need to make the changes.

Berwick: (01:03:14) I surely don't have an answer as to how to get from here to there. I kind of know where there is, that's good news. I think we could all imagine a universal system of health care that's highly equitable, that forbids the kind of greed that I've written about and we're talking about and that channels resources to the social systems that Linda's talking about. It's actually not that hard to describe. I don't know the answer. It's certainly number one question in my mind for this phase of my career, but two ideas. One is localities matter. Is it possible that community by community, city by city, locality by locality, we can achieve some major changes? I think it might be possible. It is after all, each locality, it's their own money. It's their own well-being we're talking about. And I think there could be a wave of local reforms at the municipal and the level at which people feel affection for each other. And I'm kind of hopeful that that could happen.

(01:01:19) At the national level, we have a paralyzed government. I don't expect much of it in the next few years. But on the other hand, this super saturated solution of good self-interest around reform, the number of people that really would benefit. And I keep wondering if someone somewhere could set a table and invite in these forces, business excluded populations, labor, patients who are angry about what's happened to them, set a table and pull these people together.

(01:04:55) Is that the beginning of the movement that Linda's talking about? It frankly feels ready to me. There's a kind of, it's a feeling of tension that I think holds some promise if we only could feel a way to mobilize it, whether we need a, I don't know, a Franklin Roosevelt or some national figure who says, "All right, let's get this done." We don't have that right now, but could it happen? Yes, it could happen.

Villanueva: (01:05:30) I was just thinking about sort of movement building 101 or community organizing 101 and a big component there we've kind of touched on is helping folks see their own self-interest in the change that we want to bring about. And I think if we can in some way help physicians understand that the industry as they know it, you know, and we touched on this at the beginning of this chat, is changing and things are going to get even more difficult to deliver quality care. And in order to reverse that and to make this industry better, it's going to take folks jumping in and being a part of some coordinated effort.

(01:06:12) And so I think we have to help those who are practicing medicine every day as significant pillars of this industry to have an awareness of what's in it for them to make these changes. because as you all have said, it's not about, and it's critical that these changes would improve health outcomes for people of color and Black and Indigenous folks, but it's really about all of us and really improving our systems to be healthy and to live and be in a country that is better for all people. And so that's the question I'm holding as how we can get that message across to individual practitioners around, you know, the what's in it for them to be a part of this movement.

Levey: (01:07:04) You know, I don't, again, I want to be careful about offering advice to the medical profession, but for whatever it's worth, I started my career covering local government around the country, and I was a city hall reporter in Duluth, Minnesota, among other places. And one of the things that was interesting about being a local reporter was that when I think about who were the people who were active in the civic life of Duluth, Minnesota, there weren't many physicians. When you think about who's an elected office at the local level and who is sort of leading the community organizations, there just weren't any physicians.

(01:07:50) In fact, I remember it was a very odd event when there was an opening on the city council and a local doctor threw his hat in the ring to serve out somebody's term for six months. And, you know, again, drawing more of my experience as a political reporter than a health care reporter, when I think about sort of the successes that the right has had in this country and sort of dictating the agenda and setting the stage in many senses of where we are as a country, A lot of that work began as local activism. And to the extent that I think doctors remain respected professionals, more activism, more activity at a local level to create successes, maybe something worth thinking about.

Murray: (01:08:43) I'd be interested in Don, in what you think we could do, Let's start, since we're talking to doctors, about doctors. What kind of changes should we be making in the medical school curriculum? Certainly medical students, you know, in Chicago, we have a whole bunch of medical schools. The medical students stay active. They yell and scream all the time about their curriculum and about what's going on in the community. And we've seen some structural changes. Now for the first time, the National Licensing Board, National Boards, part one is pass/fail, I think it's a good step in the right direction. So what kinds of things should we be doing with training medical students and residents to give the skill set that we need to make real changes in the health care system?

Berwick: (01:09:28) I mean, I have the privilege somewhat of teaching medical students and residents, not anyone here as much as I wish right now. But there are, I'll tell you, the ones I'm teaching, they're ahead of us on this. They're ready to be called to change. I was teaching a class at the Harvard Medical School a couple of years ago to a group of young medical students, teaching them health policy. I was talking about insurance and all that, and Medicare, Medicaid, and regulation. And this young man raised his hand and said, you know, I just have to say, this has nothing at all to do with why I want to become a doctor. He said, I want to take care of people. And I think that there's a fundamental readiness in youth here, and I don't think it's just medicine, by the way, I think it may be in nursing and other professions, they're ready if they're called.

(01:10:19) So I would have changes in medical curriculum that would allow people to see what causes health and illness and how they can get engaged in its true pursuit, and how they can be the activists that Nolan was talking about, I'm not sure learning the Krebs cycle anymore is particularly relevant to being a great doctor. I could think of lots of other things I'd rather use that time for, and I'd have to put an editorial comment in about quality improvement in my field, because I think if we really taught people how to get engaged in changing systems, some of that local change would be to get more traction. So I'm really optimistic about the youth I meet, and they need to be mobilized too.

Sivashanker: (01:11:05) Let's go back to that topic of systems for a moment because we're talking about physicians, nurses, who are, as I mentioned, they're exhausted, they're burnt out, and I think many are demoralized, to your point, that they want to be in the healing profession, they want to be engaged with people in healthy, transformative relationships, and they can't. They can't always even take care of people in the ways that they want. You may want to take care of a patient, but your institution doesn't contract for that. And I was in conversation with an executive leader who in his position has a lot of power at his health system. And they made the decision to start investing more capital funds in building clinics in historically marginalized neighborhoods. And it led to a situation where they were starting to become fiscally unviable. So doing the right thing is actually really hard as an individual in this system. And it can be very fatiguing and demoralizing. What does it take to change systems?

Murray: (01:12:06) I think it does take us thinking about this different. The nuns teach us in health care, running one of the biggest health care portions, the Catholic health care. No mission, no margin, no mission. So yeah, you have to have some kind of resources in order to employ people at living wages and provide the resources that you need in various communities. You can't get around that. It's not going to happen by magical thinking. But it can happen if we, in fact, change how health care is financed.

(01:12:42) If we get rid of the middleman, that's one reform. And I really want to say this is a reform, a single payer health system, which, after all, just addresses how we move money around this medical care system. But that is an important step of reform. It doesn't really answer the whole questions. But that would eliminate the middleman. Why should we pay large companies to just move money around? And especially when most of the money they use is not spent on actual direct medical care. So starting with proposals that insist that a certain percentage of that money in those big insurance companies be spent on direct care, insisting that those profits, that those companies be taxed so their profits can support the education of health professionals, not only neurosurgeons, but community health workers, so that we have the staff that we need, the people that we need, as Edgar was saying, to participate in this healing process and keeping our communities well.

(01:13:45) So we can start there. We can start with what happens in our hospitals, what happens in the medical schools we're affiliated with, the nursing schools that we're affiliated with. How can we make sure that students have what they need to be successful in this ramp race that we send them through in order to get license and practice in this country? I think there are lots of examples of this going around, and it means holding up those examples and saying, yes, you can do this at your hospital. You don't have to go bankrupt. Maybe they just did it too fast, but there are certain things you can do.

(01:14:18) We can change the laws about what we really mean by not-for-profit. That would help a lot. In theory, these big institutions are not-for-profit, means they don't have to pay taxes because they're giving the community benefits. But most of our states do not have a good way of defining what community benefit really means. So we can tighten up there. These are sort of dull, small things that we can do in the structures that we have today that move us in in the direction I think we're all talking about.

Berwick: (01:14:47) I would urge at some high level an interrogation of the role of profit, capitalism, and markets in American health care. Naomi Reski's just published a marvelous book on the myth of markets, basically, the Chicago School idea and she as a historian is beginning to unravel this faith we have. Yes, for automobiles and for restaurants, sure, markets are great, but for health care, a human right, that should be a human right accessible to absolutely everybody in which cooperation is far more important than competition. I think we have slipped into a belief system about markets and profit that may not be the right one. No, I'll be stronger about that. I don't think is the right one for the pursuit of well-being in America. And I think we should interrogate that together. It'll be a tough, tough interrogation, of course, upstream against a lot of beliefs and a lot of assertions. But Linda raised it earlier and I agree with it.

Sivashanker: (01:16:05) So, go ahead, Edgar. I think you're about to say, when I think about systems change…

Villanueva: (01:16:10) I teach a very simplified approach to it because it feels so daunting, right? And it's really about addressing many of the things that you all named here, which gives me hope, right, that we have to look at the resources, rules, stories, and people. And so resources, Linda, really touched on that beautifully. There's plenty of money and wealth in this country to address this problem if we had the political will to shift that, right, through taxation, through all types of other ways of redirecting and sufficient resources to this industry to take care of all of us. Rules is about changing the policies, right? It's the rules that are spoken and unspoken. What we accept sometimes as being normal and challenging that and creating new rules from everything from Medicaid expansion to you name it.

(01:17:03) And then stories, you all mentioned just for the narrative and what we believe about how health care should be delivered, what is normal, the stories that we believe about poor people and people of color, so many myths that we believe that need to be challenged to make change possible. And then the last is people, like who's making decisions, who's in power. We need to elect new folks. Someone said earlier, we need to look at what leadership looks like across this industry and have more of our people in the seats of power making decisions. So that's a very short, you know, kind of scaled down model of how system change happens. But I believe that we've hit many of those components today. And if we could find a way to get wheels moving across all of those areas, we might, you know, maybe be in Pollyanna here, but maybe we might see some progress of moving us in the right direction.

Berwick: (01:18:03) And I, yeah, that no margin, no mission line, I understand where Linda's coming from, but I have developed an allergic reaction to it because underneath that is a premise, which is that the way you make resources is to earn margin in a for-profit environment. That's where that comes from. I'd say no resources, no mission. Insufficient resources, no mission. But I think we should unmask that argument for what it is. We are a country spending $4 trillion on health care, twice as much as countries that are nowhere near 40th or 50th or 60th in life expectancy. We have plenty of money. And the problem is where that money is going.

(01:18:50) So we have no margin problem, not in the picture of this nation, In order we have a resources problem, we have an allocation problem in which we're unwilling to take the resources that we have and put them where they really make a difference. And we allow people under the no margin, no mission banner to abscond with double digit or more percentage of that total without adding value. So I would reconsider that logic. We're a country wealthy enough to put resources where they are needed to achieve health for our public. plenty wealthy enough at a lower level.

Murray: (01:19:29) I agree completely, Don. I think you're absolutely right. And that means understanding that the wealth that we're talking about, we can't allow it to be stolen. And it belongs in fact to all of us. And so that's where we get the logic to be able to allocate that money in better ways.

Berwick: (01:19:48) And it's all our money. The other make-up that we could have in terms of mobilization is that there is only one source, only one source for the funding of American health care, and it's the worker. It's the people that go to work and get paid, whose money gets taken away into premiums that are too high, taken away in out-of-pocket payments, taken away in under-resourcing resources, areas that would give them more health and well-being. It's all about the workers. If you want to trace the money, it's all their money to start with. So yeah, don't talk to me anymore about markets. Let's talk about fairness.

Murray: (1:20:31) And that's probably what we should be teaching our young healers and not the Krebs cycle, I agree with you.

Sivashanker: (01:20:40) I want to pivot to a moment of hope now 'cause this is heavy and this is big and there is reason for hope, I think I'm hearing. So let me just kind of summarize a few things I'm hearing which is first that we need to fight for our health, our collective health. That means advocacy and learning new skills in this profession, that there is interdependence, that all of our health is interconnected and depends on each other, that we cannot really achieve health without health equity and justice, and that it's actually sapping all of our health.

(01:21:15) Let's talk about the we have power part of it. And where is our power? How do we get grounded in our power individually, collectively? Where do you find your fire or where do you find your hope? And we'll just go around in a circle. And as we're doing that, I'm going to give another extra fun prompt to each of you. Given the brokenness of our system, is it reform or a complete revolution of the system that's required? So let's start with, we'll go in the order that we started with. We'll start with you Edgar. So first, where's your hope? Where do we find our power and then reform or revolution?

Levey: (01:21:57) Yeah, my hope is in the young folks. You know, I'm really happy to hear that in the medical schools, they're teaching some of this stuff and that younger folks in the profession are feeling fired up. And we always know that young people are on the forefront of change and social movement. So really hope that not to put, you know, our mistakes and our generational curse is on the backs of young people, but really inspired every day by the people that I meet who are leading change in our communities.

(01:22:32) You know, it's an interesting question, this reform or revolution. I consider myself to be a bit of an incrementalist. I fantasize about burning it all down, but I think, you know, maybe this is being a product of my community and coming from poverty. I feel like I need something to hold on to on the way there. And I do believe there are really sweeping reforms that we can see in an incremental basis that would have lasting impact. So I'm a person that's driven by a vision for burning it down and what is possible. But my focus has been working within the current system and making changes and disrupting there where we can. Linda?

Murray: (01:23:16) Well, I think that all social movements and society in general is multi-generational. And so even though young people are often energetic and enthusiastic—that's what happens when you're young—I don't think this is going to happen without a multi-generational approach where we have all the generations excited about changing things. I'm not an incrementalist, even though I have to deal with the reality of the world. I don't think you can imagine a completely different situation if you're not willing to discard what we have. If you're not willing to question, as Don has said, the right for people to steal money just for their own personal use, we're not going to make it very far.

(01:24:00) And so while I recognize that I may not see the changes I would like to see in my lifetime, but if we don't have that vision, If we're not willing to risk what it takes to have a revolution, then we're unlikely to have one. If we can't imagine ending—it's hard to imagine incrementally ending chattel slavery. You have to abolish chattel slavery. And if we're willing to imagine that and fight for that, then we have some hope of improving the lot of people who were former slaves. I wouldn't exactly call us free right now, but at least we're not in the kind of chattel slavery that we saw in the 1700s. So I'm for revolution.

Sivashanker: (1:24:45) Thank you, Linda. Don?

Berwick: (01:24:48) Yeah, I'm too old for incrementalism. I'm too fed up. I don't see a stepwise move toward the health care that we deserve at a price we can afford. It's not going to happen, and the old myths of markets and I don't know, and public-private partnership words and things, they've lost their attraction for me. Too much has been too wrong for too long. I do agree that youth gives me hope all the time. That's putting it very mildly. I mean, I just, I'm super excited by the young people that I encounter.

(01:25:31) So yeah, I'm more on the revolution side, but revolution can take funny forms. For example, when Lyndon Johnson, with the wind at his back politically and with enormous savvy, was able to pass Medicare and Medicaid, that was a phase change. That was not the system we had. It was completely new. Government was now in the insurance business. And that has now changed the fate of 110 million Americans every day. That was a revolution. It occurred through very skillful government leadership and not always so highly motivated, but Johnson was a very selfish person apparently, but man, was that a change. More visibly, you have the Edmund Pettus Bridge and when there comes to be a moment in time when mentality starts to shift, that's more dramatic.

(01:26:21) But my whole career has been on incremental improvement, quality improvement projects and step-by-step reduction of infections or pressure ulcers or reduction of waiting times, I don't think it's going to work here, not for what we're talking about. And so I'm for revolution. I'm looking for the barricades and the banners and the platform. Haven't found it yet, but I am, I'm looking.

Levey: (01:26:53) Well, I guess I end by just very quickly telling you a story. I remember right after the passage of the Affordable Care Act, I went down to the Arkansas Delta, which is the Arkansas side of the Mississippi Delta. It's one of the poorest parts of America. And there was this beautiful, gleaming new FQHC that had been built with money from the Affordable Care Act. And The patients who were there had gained health insurance through Medicaid expansion made possible by the Affordable Care Act. And I remember one of the doctors there told me that the patients who came in there who were overwhelmingly black and poor and had been living with terrible access to health care for generations had started dressing differently when they came to the doctor at this FQHC because the message that was transmitted as a result of having health insurance and being able to go to a place that was beautiful and that gave a sense of worth to the people who were cared for there, changed the way these people thought about medical care and getting it. And to my mind, that is a cause for hope. I mean, this was, the Affordable Care Act was not a revolution, it was incremental, but it made a huge difference for a lot of people. Not enough people and it didn't change enough, but seeing it on the ground in Arkansas, and I can tell a million stories like this all over the country, I think it is a cause for hope.

(01:28:16) That being said, I do agree with Don too that barricades are needed. We're telling stories of people's whose lives have been ruined by, essentially by our health care system. We're going to keep telling those stories because I sort of feel like people need to get angry and to demand something different. And until people rise up and demand it, I'm not confident that the system will change by itself.

Sivashanker: (01:28:43) Edgar, I'm going to give you one last chance if you'd like to change your vote to the peer pressure. (All laughing)

Villanueva: (01:28:50) Yes, I am definitely on the side of revolution. I think both are required. I think we need to continue to chip away at what we got and we do need to be angry about what's happening and fire it up and demand the changes that are necessary to improve our system.

Levey (01:29:12) So I'm with y'all.

Sivashanker: (1:29:18) Thank you so much. Thank you all. So that's all the time we have today. I'm going to hand it back over to Emily to close this out, but really appreciate your insights today. And Emily, over to you. Thank you.

Cleveland Manchanda: (01:29:30) Thank you all so much for joining us. Thank you to each of our speakers, to our moderator. Thank you most importantly to our audience, to all of you who are listening and watching along with us. We truly appreciate the thoughtful questions that you've submitted, some of which we were not able to address in our conversation today. I'd like to invite you to provide feedback by completing a brief post-event survey. That survey will be linked in the Q&A on the side of your screen here, and will be emailed to everyone who registered for this event. A recording of the conversation that we just heard will be available both on the website and on the AMA's Ed Hub, where physicians can claim CME credit for attending. Before you go, I'd encourage you to please register and join us for the next conversation in the National Health Equity Grand Rounds series. The next conversation will focus on health professionals education and our health care workforce. The next event, Breaking Down the Ivory Tower, Building the Workforce America Needs, will be broadcast on Tuesday, August 8th from 2:00 to 3:30 Eastern. You can register through the National Health Equity Grand Rounds website using this QR code here are going to healthequitygrandrounds.org. Thank you again for attending today, and we look forward to seeing you again in August.

Audio Information

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If applicable, all relevant financial relationships have been mitigated.

Accreditation Statement: The AMA is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement: The AMA designates this Enduring Material activity for a maximum of 1.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


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