Welcome to Chasing Life. As you no doubt know by now, we are currently in the midst of a government shutdown. And if you've been tuning in, you know that healthcare is really at the heart of it.

Senator Sanders, you've said 50,000 people could die from ACA subsidy cuts...

'Just this week, CNN's Kaitlan Collins moderated a town hall with Representative Alexandria Ocasio-Cortez and Senator Bernie Sanders. It was all about the shutdown. And there was this one moment in particular that really gave me pause.

What you just said about 50,000 people dying a year, this is based on studies done from the University of Pennsylvania and Yale. You take 15 million people off of their healthcare, by and large, low income and working class people, what do you think is going to happen to them? They don't go to a doctor, they have chronic problems. They will die.

So I decided to look into that study that Senator Sanders is citing, and it's pretty legit. In June, researchers at Yale and UPenn sent letters to senators with their findings, which were that an estimated 51,000 preventable deaths will occur annually if all the  if all the planned cuts to federal health spending are enacted.

I think our healthcare system is broken. I think it is dysfunctional. And I think it's on the verge of collapse.

Look, perhaps we're a bit jaded from the news cycle, maybe we're just tired of hearing politicians speaking in extremes. But here's the thing, my guest, who is very much not a politician, she sounds pretty alarmed as well.

You know, I see some things that are hopeful and some things that are not. The question is, will they be addressed before the system just really falls apart? Because I think it's pretty close to doing so.

Dr. Elisabeth Rosenthal. She's not a politician, as I said, but she's done basically everything else. She was a trained physician and ER doctor before turning to journalism. She was at the New York Times for two decades plus. Now she's senior contributing editor at KFF Health News and also author of a really interesting book on the healthcare industry titled, "An American Sickness, How Healthcare Became Big Business and How You Can Take It Back." That book also has a very strange and tragic connection to Luigi Mangione as well. It's something we'll talk about later in the podcast. But today we're mostly going to be discussing the U.S. healthcare system, its complexities, potential solutions, and how the crisis at the center of the shutdown could impact you. And on Tuesday, we're going to bring Dr. Rosenthal back again on Paging Dr. Gupta. And we're going to talk about how to navigate the open enrollment period. It is complicated, it is confusing, even for me. Elisabeth has some great tips. For now though, let's hear from her and find out what's really behind this healthcare debate and its role in the government shutdown. I'm Dr. Sanjay Gupta, and this is Chasing Life.

Well, Dr. Rosenthal, thank you for joining us. Welcome to Chasing Life.

Thanks for having me.

The name of the podcast is Chasing Life. Do you feel like you're chasing life?

Every day I feel like I'm chasing life, and particularly about this topic that I'm obsessed about. I'm just trying to figure out how to make it better for people, which has kind of been my journalistic mission for decades.

Yeah, well, I do want to get into that background because I find it fascinating. And I think you and I share a lot of connective tissue in this regard, but what is the specific topic that you find fascinating?

Well, you know, generally our healthcare system doesn't deliver to patients in terms of quality of care and in terms of the prices we get charged. So what I worry about right now, and particularly in this season of renewing insurance, is that people avoid going to see doctors and avoid going the hospital because they're just afraid of the bad experiences they've had and they don't trust doctors or hospitals because they had bad and very expensive experiences. We did a podcast and a series of articles called Diagnosis Debt. And it's about 100 million Americans have medical debt now. And that's just going to go up if people don't have insurance. And what we're seeing now threatens to leave millions of more people uninsured.

So when you talk about the bad experience, you're primarily talking about it from a financial standpoint. There's other things, obviously, but the sort of diagnosis debt, as you call it.

'No, I think it's multifaceted because I think most hospitals run as businesses now, I mean I think you and I both know that and one thing I'm obsessed with is ER boarding, how much time people spend in emergency rooms, that's particularly older patients and you know that's largely a financial decision I think. My husband who died earlier this year--

I heard that. I'm sorry, Dr. Rosenthal. They shared that with me. I am sorry.

That's okay. Well, he and his final admission spent three days in the ER and I knew there were elective admissions coming into the hospital. I saw other patients going upstairs, but I think, you know, this is an older guy with stage four cancer who's just going to take up a bed and won't generate any revenue and will be a placement problem, you know if he doesn't happened to die on this admission, which he, in fact, did. And so I think it's really multifaceted. You try and make an appointment for physical therapy or a neurologist or an endocrinologist and it's, you know, two, three months out because hospitals want to run as full ships all the time and the waits are terrible. The phone trees? You know, talk about a bad use of AI assistance. You know, there are multiple bad experiences that go well beyond the cost, but I think they're all related to, you know, what I wrote my book about, how healthcare became big business. And I'm not sure there are good ways to take it back individually, frankly.

OK, well, that's sort of a little bit of what I wanted to pivot some of this conversation around, which is, how did we get here? And how do we get out? So let's start with, how do did we get here, because you and I have both evaluated healthcare systems around the world. And I think when you do that, the consensus always is, look, there are things that work well with our healthcare systems, but many, many things that don't, some of which of you have alluded to. Did we get here through a process of natural evolution, or what were the weird sort of forces that got us to this place?

'Well i would call it more unnatural evolution. You know, basically, the idea of insurance goes way back to the turn of the last century, where it was really more like disability insurance. It was pay, which you got because you couldn't go to work, and the hospital stays were inexpensive so it didn't it really wasn't about that. Then around that time a teacher's union in Texas decided to have insurance for their employees, and some employers developed on-site clinics to help their employees. But the big change was really post-World War II when there was a labor shortage and companies started offering health insurance as a perk, you know, and that was a big thing. So then there were all these people who had insurance which was tied to their jobs, and more people got insurance that was tied their jobs. And then in 1963, people over 65 didn't have jobs, so they were just like flailing in the wind, unable to bear the cost. So Medicare was started to help them. And I call insurance the original sin, not because it's bad to have insurance, it's kind of a must-have, but because it, for many years, separated the patients from the cost. So, when I had my children in the '90s, I paid nothing. I paid like to have cable TV in my room. So I didn't really care how much was being charged. And of course, what happens kind of organically or evolutionarily is some doctors realize, hey, you know---entrepreneurial doctors---it doesn't matter how much I charge because the patients aren't going to feel it.

Right.

'Another big step was You know, in the 1990s, there was this era of HMOs, and they were really putting the squeeze on hospitals. And so hospitals called in business consultants, like McKinsey, Bain, Boston Consulting Group. They looked at hospitals' procedures and how they operated, and they said, guys, you're leaving all this money on the table. Like, when I was an ER doctor, I came with the ER. But the inside of business was like, wow, you can charge separately for that doctor and for that IV bag and for the nurse who's inserting the needle. And PS, like when patients are in the recovery room, why are you giving that away for free? You can charge and not only that, You can charge in 15-minute intervals. And you and I know, you're a surgeon, like, why are people in the recovery room? Sometimes it's because they need to, like come out of anesthesia, and sometimes the extra half hour is because their team is having dinner, you know. And so, you now, we've gotten to this place where everything is billed, each little, every pill, every interaction. And then, as a reaction to that, the insurer said, oh, we've got to let patients have some skin in the game. And that started kind of slowly. There were co-pays, which were kind of minimal, and there was a deductible, which wasn't very much. But those little bits of change didn't really, patients didn't feel them enough. So over time, the deductibles have gone up. So I think some people have $9,000 deductible plans. In addition to co-pays, there's co-insurance, which is 20% often for hospital stays. And you know, man, if you're in the ER for four hours, that's 10,000 bucks probably, and your portion is $2,000. And so I think we're at this critical juncture, where we put efficiency ahead of patient care, and we've sacrificed a lot of patient-care in the name of efficiency. And I say 'we' as a kind of lapsed physician, but we've lost the population in that process.

'Let me focus in on something that you brought up a couple times. This idea of cost-sharing, of having skin in the game. When you had your kids back in the '90s, it was free. Patients were largely insulated from cost. So they weren't effective negotiators in terms of trying to bring those costs down because they didn't really care. They didn't even see the numbers often. Then you started having more cost- sharing, sort of incremental at first, in terms co-pays but higher, higher sort of cost sharing with high cost deductible plans, things like that. Is that a good thing or not to have this increased cost sharing? Does it actually achieve some of the goals you're talking about?

'I don't think so? I think it's gotten so high. You know, it's always a question, like with plastic bag fees, is 10 cents enough to get people to bring carrier bags? But if you charge too much, they won't go shopping. They won't eat. That's obviously an exaggeration. But I think that is what's happened now with cost sharing, you know, patient-centered, cost-effective care. Great idea. But they've become kind of slogans that, you know, what does it mean to have skin in the game? I think I said in my book, it's more like having a kidney in the game now, you know.

That's interesting.

You know a $7,000, $5,000 deductible when most Americans don't have $500 in their savings account, what's that going to do? It's going to make them say, except in a dire emergency, I'm going to stay away from the healthcare system.

Should it be different for different people, depending on your income?

'We've kind of tried to jury-rig the finances, you know, over and over again the whole time I've been a physician, and kind of nothing is worth. The healthcare system is kind of incredibly agile at playing to the newest incentives and doing end runs around them, so yes, that is a concept. It would be really hard to roll out that kind of idea with all the different incomes and all the different changes in incomes. I mean, in some ways, that is what Medicaid tries to do. It says, if you're below basic income in forty states but not the other ten others, you can get on Medicaid where you will have almost no cost-sharing, right.

Right.

Our system keeps getting more and more complicated. By these kind of interventions rather than simpler. And you don't have to have a national health system if you don't want it. I mean, Medicare for all would be fine or you could slowly lower the Medicare age as Hillary Clinton had proposed as a candidate or you can have a public option, which would basically throw down the gauntlet to the insurers and say, if you can't do as good as this, you know, people can walk with their feet. Or, you know, Germany, Switzerland, they have systems with lots of insurers, but they have a lot more price regulation. And, this is going to cause fire to come out of some people's ears: The insurers have to be not for profit.

There you go, you said it. Where people seem to be in agreement on is what you started off by saying, which is that we've spent a lot of money, four and a half trillion dollars on healthcare, and we don't have what we should have to show for it. Right. I think, regardless of your political party or whatever, I think there's a lot of agreement on that, even within the medical establishment. I don't think anyone is raising their hand and saying, this system works perfectly. Not even close. And again, I don't want to get you in any kind of trouble here, but if you could wave a magic wand, what would the system look like? Would it look more like a single payer system?

It would look more like a system where price was controlled to a manageable point, whether by some kind of government negotiation, as Medicare does. I mean, there are a lot of ways to get there, the public option. I'm not dodging the ball, really. I don't think you either would want to say, this is what I think we should do, because it will ultimately be a political decision, which one the American public can support. I think any of them would be fine, you know, when people say, oh, Canada, we could never do that. I mean, you what happened there and the provincial minister named Tommy Douglas who really believed in this idea of a provincial health system and fought and he tolerated doctor strikes. And when that province got a provincial health system, the other provinces all said, wow, we want that too, you know? So will a state figure it out and then we'll all just do what that state did? I just think there are so many things we could choose and instead, you now, we all kind of put our head in the sand. And I think part of the reason it's not a big political issue is that patients don't interact with the medical system that much. So, you know, they get a bill that's ridiculous, or they're on a phone tree that takes two hours and finally get an appointment. And then they're like, ugh, you know, I hope I don't need a doctor again for a long time. But you know, it's the physicians who deal with it every day. So last weekend I was speaking to physicians in Minnesota and I'm like, guys, you're stuck in this system. Now more than half of physicians say they would be okay with Medicare for all you know that's a real sea change from when I was practicing

'Yeah, I've sort of witnessed this firsthand over the last 25 years, as I've seen physicians that are colleagues of mine, friends who it would have been anathema to suggest Medicare for all. And that's that Bernie Sanders hippie kind of stuff, right? And those same people now recognize that a large payer like that might have a lot of leverage and might make their lives a lot simpler overall. Like I said, that nothing is all good or all bad. I mean, you do have other problems that may come with it in terms of patient experience overall. But I think even if you go, like I interviewed President Obama back around the passage of the Affordable Care Act. And we talked about how, what it was like to get it done and what had happened back in '94 with the Clinton healthcare plan, all of that. And he made this comment to me that, look, if we could start all over again, go back to pre-World War II time that you're talking about, that's probably where we would have landed on a single-payer, largely government-run sort of system. But now, in order to transform healthcare, you're trying to change parts on a really, really big and fast-moving train, and you can't do it. That's sort of the excuse I get. Is that a fair excuse?

'Well, yes, it would take a lot of political will. So many parts of the system now were never meant to be as they are now. I mean, insurers initially were not-for-profit, right, then we allowed them to convert to for-profit status. So now, who's their primary, you know, you and I have probably heard that as a physician, to whom is duty owed the patient? Well, now to who is duty-owed? You know, your employer? Who is a hospital or an insurer. And I think a lot of people hate that. And I hear from physicians all the time how unhappy they are that they're pushed to meet metrics and economic efficiency and return on efficiency. But they are. Likewise, you know, not-for-profit hospitals. And the ACA did something about this, but it was kind of a baby step. Sorry, I believe you work at one, but they don't run that differently than for-profit hospitals. They're run mostly by business people. There's a lot of like, the patients are kind of just the throughput of the organization. And so I think there's going to be incredible resistance unless there's the force of government saying, we got to do this. You know, you don't want this thing we have now where you're negotiating every single literal interaction. And you know, when people worry about a big government system, countries that have a lot of insurers and price setting, it's not like Big Brother comes down and tells you what you can charge. I mean, it is a collaborative thing between economists, physicians, and the government. And, you know, almost like the ACA ruck does, but there it's just physicians fighting each other for a piece of the pie. So I think there are ways, but we don't ask, for example, from our not-for-profit hospitals. They're supposed to have their not- for-profit status because they do charity care and community benefit. But you look at the 990 statements. And, it's hard to see that as real community benefit, most of what they do to claim that status. And yet, and here's the big problem, when anyone tries to move against insurers or pharma or PBMs or hospitals, they are way better lawyered up than states. They have way more lobbyists than states. I live in New York. You know, the Greater New York Hospital Association? Who's the biggest contributor to most politicians in the state? So it's really really hard to move in less there's someone - And I'm not running for anything - who really believes this is an important issue and in less people start voting as a this is the life issue that it is when I hear people go gas prices and egg prices, I'm like, look at your healthcare, look at your premiums.

But this gets at your point, I think, again, that it's a black box for people how health care pricing works. They don't vote on this issue. And we saw that in the early 1990s. Obviously, we saw what happened with the Affordable Care Act got passed, but, you know, It wasn't one of these core issues. It comes up again here and there but for a large percentage of Americans, politicians may not use this as a central wedge issue because they don't think it's going to help them get elected.

Right.

Necessarily. And people are pissed. I mean, look, I was surprised after what happened with Luigi Mangione, assassinating a man on the streets of New York and then having this manifesto, and which he cited some of your work and Michael Moore. By the way, what did you think when you saw that? When you saw you were cited in that?

Well, of course, I thought that no one should kill someone because they're pissed with the health care system. I mean, that's unconscionable to me. So I did not like seeing my name there. I did feel like, OK, why is this there? Why is this young man so enraged? And I think there's just this deep well of frustration with the health care system that politicians aren't addressing and aren't tapping into, and I wish they would.

Yeah, I think that's a very responsible and fair way to answer that. I mean, it was shocking to me.

Totally.

And I think equally shocking was the response in some sectors of our population celebrating assassination.

Right, right.

I mean. But you've done important work. You put good information out there. And I, think it does raise a lot of questions about our healthcare system for people overall. Again, I, most people would concede it doesn't work really well. We spend way too much, twice as much per capita as the next country that spends money on healthcare. And again, our mortality rates, our overall patient satisfaction, there's a lot of things that we need to be doing.

I'm speaking with Elisabeth Rosenthal. She is author of 'An American Sickness.' After a break, she's going to explain why this government shutdown makes open enrollment especially tricky this year.

Welcome back to Chasing Life. My guest, Elisabeth Rosenthal: trained physician, author, longtime health journalist. Here, she lays out the impasse that Affordable Care Act enrollees are going to suddenly be facing.

The problem is, you know, all of those people who we, in the last 10 years, directed and encouraged to use the Obamacare exchanges, the ACA exchanges, which have, you know, raised insurance rates in this country by tens of millions of people. But what's happening this year is during the Biden administration, the prices of subsidies were going up and it was during COVID, so they issued what are called premium support payments. So there were subsidies that if you had a certain income, you put it into the computer system, it's not easy to use, but you could do it. And it would say, oh, you know, the normal premium would be $900 a month, but you only have to pay $200. So it tremendously helped a lot of people get on insurance who otherwise might have said I can't afford that. Two things are happening right now. Those subsidies were meant to expire at the end of 2025. This is what the government shutdown is all about right now, the Democrats want the subsidies to continue, the president and his allies have said no way. If those expire, a lot of people will be forced to drop insurance. I mean The Kaiser Family Foundation or KFF estimates that premiums will double on average or the medium premium will double. Some people will find premium increases of 70 percent and the problem is we already know that will happen because the insurers, this is not like, you know, Oh, the sky is falling, the sky is falling. The insurers have already submitted their rates for the new year. And they are you know increased by sometimes eighteen percent sometimes thirty percent these are big increases and everyone you know in healthcare we all go Oh, you know, it's only increasing ten percent this year. I mean, if your rent increased ten percent every year there would be upheaval in the streets but somehow we accept this and this year, if those premium subsidies aren't extended, patients will feel the full force of that increase, and it's estimated that probably over 20 million people or as much as 20 million could decide to go without or not have the money to do it. If you care about healthcare, that's a really bad thing, right?

So to be clear, two things sort of happening at the same time. Rates going up and subsidies going down or vanishing completely in some cases.

Well, and they're not entirely unrelated because the assumption of the insurers who are always playing an actuarial ball game know that if the rates go up a lot because the subsidies expire a lot of younger people will just leave the risk pool and that will leave an older sicker risk pool to insure. So they're calculating that. But there's also a lot other things going on, you know, prices have been going up anyway. Staffing costs have gone up. The tariffs may affect how much it costs to buy medical supplies. So they're bundling all this stuff into their assumptions. And the thing that's going to get really tricky, and I can't overemphasize the chaos that this will cause, the government is shut down now, right? We don't know if there will be subsidies or not. People in Idaho are choosing plans today. They will see a price that will probably make their head explode, right? Because the assumption is if they're not extended, the subsidies will expire. So they may go without insurance when, if the subsidies are extended, they would have bought insurance. We're getting pretty close to November 1st, where the period opens up for everyone else. Will the sites be updated? Will they have time to update with the new calculation of what you owe? It really is going to be just unbelievable chaos and, you know, in the end, when things get that chaotic, these sites are already hard to deal with, people are just like, I give up, you know? And it's just a terrible moment if you're me and obsess about this all the time.

Yeah, I mean, people aren't going to know how much ultimately it will cost, but right now they'll see a price that reflects increased insurance rates and little, if any, subsidies.

Right.

And it will make their heads explode. We'll come back to that in a second, but going back to what you said earlier, it's one time a year, in part because you don't want people to say, Hey, look, I've gotten a diagnosis, now I'm going to buy healthcare insurance. That's not a system that works. But there are things known as qualifying life events.

Yes.

So what are those? What would allow you to buy healthcare insurance at a time outside of open enrollment?

Yeah, outside of open enrollment, if you get married, you get divorced, you lose a job, you have a baby, there are all these things that obviously would change your ability to have insurance. So at those times, if, if experience one of those qualifying life events, yes, you can go back and on the market and buy insurance.

If these subsidies everything that we're hearing with these subsidies happens and then we get subsidies again. Would that constitute a qualifying life event?

I don't think anyone has considered that possibility. So that's why I said it's just going to be chaos because you may get a notice from your insurance saying, oh, actually, your premium isn't $700, it's $200 again. If you chose the $700 but maybe if you chose no insurance, you would be stuck with no insurance. I mean, you know, because the government is shut down. This seems to be an issue that the Dems and the Republicans are arguing mightily about and intransigently about. I don't think we've thought past the, will there be subsidies or not? You could always legislate differently. I mean, as President Biden extended open enrollment during the pandemic, so you could say, if you were one of these people, here's your second chance, but, um. You know, it's hard to be optimistic about good things happening at the moment because, you know, even on this step one of should there be premiums assistance or not or premium subsidies or not, actually they're called enhanced premium subsidies officially, it is hard to get to step two.

You've been at this a long time, what do you think is going to happen over the next couple weeks?

I can give you my optimistic view and my pessimistic view because I really don't know which is right. Optimistically, we've calculated at KFF that 80% of the people who will lose enhanced premium subsidies are in red states. It will hurt the Republicans' base to do this. And I'm hoping the optimistic view is, I think, a lot of the red state governors have spoken out about this, some congressmen have, not a lot of senators. But that may you know optimistically that could rule the day because it should hurt Republicans in the midterms if they let this go through without the premium extended premium subsidies. The pessimistic view is, you know, the Trump administration draws a line in the sand and his friends in Congress back him up on that. I mean, Republican governors have spoken out against this, but you know they don't have a vote in Congress, so they can't make this go away.

Is there anything about this that makes sense to you? I mean, this is obviously harming people who, just being charitable for a second, like what is driving this?

Well, it costs money, right? It costs money. It costs that's all that's driving it.

But out of all the places to save money, harming your own constituents by putting their subsidies at risk, look, maybe I'm just sort of riffing with you here, but is that the place to save money?

'Well, I don't think it is, but again, I think there is an argument that one could make, which I think I agree with, but it's not appropriate to apply to the current situation, which is we keep putting band-aids on a broken health system, so when subsidies go up, we don't say, gee, why are subsidies going up? What can we do systemically to prevent that? Instead, we just say, okay. Patients, we're going to give you more money to allow this to keep happening. So I wish our country was more inclined to do more regulation of insurer prices and hospital prices, which are all kind of, they're linked together, and pharmaceutical prices. Don't forget that. We pay, you know, more than twice as much as any other country for the same exact drugs.

Who gets harmed the most by what's going on right now with the government shutdown? I would assume it's people who are poor, that's who always gets harmed most, but people who're going to have a hard time if these subsidies don't come through having healthcare insurance, at least for the next year.

Well, I think that's not an accurate impression because the poor can go on Medicaid, right? I mean the poor are going to be harmed by the shutdown in many other ways, right, the end of some of the Medicaid, I mean, the work requirements and, you know, the reductions and SNAP and all that kind of thing. So you know the people who are going be hurt most by these subsidies going away are not the very poor. They're people who work for small companies, they're entrepreneurs, they're singers, they are actors, they, you know, geological engineers who are consultants. They're hardworking people who really need these subsidies to be insured and they want health insurance. You know someone who will be affected by these subsidies, whoever you are. It's going to be really hard for them. And boy, you know, you'll see their GoFundMe account if they get sick, if they're uninsured.

If you were to write another book at this point, by the way, are you thinking about it?

Yes and no. Well, the problem is most of what I wrote in my first book, which is now eight years old, is still relevant, which what really disturbs me. So I didn't foresee at the time the incursion of private equity into healthcare. I would write about that. I would about vertical consolidation. And I think the How you can take it back part of my book was lackluster because I don't think patients have much clout. I would write about doctors unionization and the rising politicization of doctors. You know, I see some things that are hopeful and some things that are not. The question is, will they be addressed before the system just really falls apart because I think it's pretty close to doing so.

Well, I would be first in line to read it. I learned a lot from you just talking today. So, and I really, really appreciate your time. Fingers crossed for what happens over the next couple of weeks. And thank you, doctor.

Thank you for having me.

Of course. Elisabeth Rosenthal is Senior Contributing Editor at KFF Health News and the author of "An American Sickness, How Healthcare Became Big Business, and How You Can Take It Back." That's all for today's episode. In the meantime, I'm going to talk to you on Tuesday for another episode of Paging Dr. Gupta. We are going to go over the basics of health insurance coverage and your options for open enrollment. This is probably something you need to know. Until then, keep chasing life.