A Second Opinion with James Capretta | A Second Opinion Podcast

A Second Opinion with James Capretta

In today’s episode, I’m joined by my good friend James Capretta, a healthcare entitlement and physical policy expert who currently holds the Milton Freedman chair at the DC based think tank, the American Enterprise Institute. Jim began his career by serving for 16 years in senior positions in the executive and legislative branches of the federal government. He was an associate director at the White House office of management and budget in the George W. Bush administration. There he handled healthcare, social security, education, and welfare programs.

Like me he also spent time in the Senate. He was a senior analyst at the Senate Budget Committee. And in recent years he and I have worked together to find bipartisan healthcare policy solutions at the Bipartisan Policy Center in Washington DC where we are recording today. And now please join me and our guest for A Second Opinion. Jim, we have so many things to talk about today and let’s just let it flow coming in. But a couple of issues I want to talk to you about because being here in Washington, DC and again A Second Opinion Podcast is here in Washington for the reason to be able to talk and have the sort of discussions that is a lot of policy intersecting with a lot of health and healthcare and intersecting with a lot of innovation.

Bill Frist:                       Welcome to A Second Opinion podcast where we are rethinking American health. I’m your host, Senator Bill Frist. To make sense of all the dynamic perspectives in healthcare, you need a trusted source engaging at the intersection of policy, medicine, and innovation. You need A Second Opinion, a podcast where it all comes together. In today’s episode, I’m joined by my good friend James Capretta, a healthcare entitlement and physical policy expert who currently holds the Milton Freedman chair at the DC based think tank, the American Enterprise Institute. But before we get started, I want to thank our sponsor MEDHOST, a trust in the HR for healthcare facility. Now let’s turn to the episode.

Bill Frist:                       Jim began his career by serving for 16 years in senior positions in the executive and legislative branches of the federal government. He was an associate director at the White House office of management and budget in the George W. Bush administration. There he handled healthcare, social security, education, and welfare programs.

Bill Frist:                       Like me he also spent time in the Senate. He was a senior analyst at the Senate Budget Committee. And in recent years he and I have worked together to find bipartisan healthcare policy solutions at the Bipartisan Policy Center in Washington DC where we are recording today. And now please join me and our guest for A Second Opinion. Jim, we have so many things to talk about today and let’s just let it flow coming in. But a couple of issues I want to talk to you about because being here in Washington, DC and again A Second Opinion Podcast is here in Washington for the reason to be able to talk and have the sort of discussions that is a lot of policy intersecting with a lot of health and healthcare and intersecting with a lot of innovation.

Bill Frist:                       And we’re right at that nexus and this is a perfect conversation to have here in DC. But let’s touch on Medicare for all the current issues that are out there today. We’ve got elections coming and we don’t have to go deep into the elections, but your average person listening, he does have this curiosity about what’s really going on in Washington. And is it background, is it what we hear about, is it Medicare for all coming in.

Bill Frist:                       And then there’s this whole issue of price transparency and let’s get through those three because the fascinating, and I’m looking forward to the conversation. When I was here 12 years ago, lived here in Washington DC, deductibles were $200, $250 for our healthcare plans and typical health care plans. Not just because I was here in Washington and today it’s $5,000. My sister in law broke her wrist and it’s been two weeks and it needs to be repaired and she went through all the regulatory stuff to get approval for it, but her deductible is $6,000 and she has to come up with $6,000 by tomorrow Friday. This is a real story. And so that scramble. We, I mean a lot of people felt that higher deductibles would lead to more responsibilities, smarter consumers asking the right questions, prices coming down. So let’s start with that and take it from there in terms of where we are today, in terms of price transparency on the choices that are being made with higher deductible.

James Capretta:            Yeah, no, these are all really important issues. I do think it’s related just to start off with some of the reasons why there’s a lot of interest in doing something more on health care policy wise, right? Because I think the voter sentiments because they’re facing those kinds of situations you just described are pressing their elected leaders to say this is kind of pushing me to the limit. I’d like to see if you could do something to help. Right? So when the see these voter surveys and the healthcare is rising to the top of the list again, and I scratched my head when I first started seeing that a few years ago. I thought, well healthcare, we didn’t, we just do healthcare, but it’s coming up again. I think in part because of just the situation you described, people seeing a lot of higher deductibles and not dealing with it as well as we had hoped they would.

James Capretta:            So how to begin? Well, I mean how did that happen? Well, it happened because employers are under financial pressure. Health expenses are a big part of their employee compensation packages and they’d like to keep it under control. But we in the sense in the policy community have to take some of the accountability here because we did encourage it a little bit through health savings accounts, right? So we created health savings accounts. You try to set aside a little bit of your own money. You have a higher deductible, but you can pay for it if you saved your own money. That was the theory. And it has worked to some degree. People with higher deductibles do forgoes some care. Probably a lot of it not totally necessary. So maybe there’s a little bit of a benefit there. The problem is that this business of shopping for care being able to say, well I’d like to get a good deal and figure out how to get the best price for that from the best doctor.

James Capretta:            That is hard to do. And that hadn’t happened so much yet. Now there’s a lot of tools and this is right in what you’re interested in. I think in with your efforts here. There’s a lot of tools out there now. Employers have built them. The IT community is building them. States are building them to say, hey, we’re going to put in your phone in your hands some ability to navigate this a little better. But it’s rough. It hadn’t taken off quite yet. It’s just getting started. And a lot of it is not quite what is totally necessary to make it easy for someone to find a better deal.

James Capretta:            So I think that mix of issues there is like how to put it, we’ve got the higher deductibles, but the tools to deal with it haven’t caught up. And maybe that’s why the politics are moving towards saying, hey, is there another way to do this? Could the government figure out a way to solve this for me so I don’t have to solve it for myself?

Bill Frist:                       And the price transparency. You’ve written a great paper which I am preparation for today read on the price transparency itself and I’ll make sure that we have that on our website-

James Capretta:            Thank you, yeah.

Bill Frist:                       … Which is asecondopinionpodcast.com for our listeners. The premise and then what did you find and you gave some great examples and they are the Mennonites and others, but tell us a little bit about sort of what the thesis of that paper was.

James Capretta:            Well, it really gets down to how to make the tools that are out there a little bit more refined to give the consumer exactly what they would need to be able to compare something. Now let’s start with the fact that as you know better than anybody, maybe half of healthcare isn’t going to be maybe a third of healthcare isn’t going to be a minimal to consumer price shopping. You get diagnosed with something pretty serious, a good physician will get you going, but they’re not going to promise you a total course of treatment at that point because there’s a lot of complications. There’s a lot of unknowns. It’s contingent on what they find, how you respond to a first line therapy. And so you don’t know the all in price at that point. If you’ve got cancer, there’s a lot of forks in the road you’re going to get to and you’re have to go down one or another.

James Capretta:            And so you don’t know for sure. So let’s just set aside, some things aren’t going to be amenable to price shopping in advance. Now that doesn’t mean though there isn’t a lot that is, right. So you bust up your shoulder or you tear something in your knee and you need a surgery to repair it. That’s fairly common. Fairly routine. Yeah. There could be some contingencies, but it’s physician who seem one, they probably seen 100 and it’ll look exactly like it, right?

Bill Frist:                       Yeah.

James Capretta:            And so they know sort of what’s going to be involved in taking care of that. They could set a price for that. So my basic theory is let’s figure out what’s shoppable so to speak and ask our provider community to set a price for all the stuff that is fairly common. I wouldn’t use the word routine.

James Capretta:            Some of them are pretty serious but common and repetition in terms of the number of patients that get it and get a price for it. Tell us what you would charge and then you can say to the consumer, you can look that up now. Everybody’s pricing the same thing, right? There ain’t going to be any variation on what they’re going to do to you. There’s going to be some around the margins, but basically when they repair this thing through a surgical procedure, it’s going to be the same. Whether it’s Dr. X or Dr, Y and let’s get an all in price for that. I’ll tell you what the facility fee probably done in an outpatient basis a lot of them, your facility fee. The surgeon fee, the anesthesiologist, that post-surgery therapy.

James Capretta:            Tell us what it would all be and then that consumer can look it up and say, I’ll compare this one to that one and see what the price is. Now there’s one other piece though, because as you said even with a $6,000 deductible, a lot of people will blow through that. If something serious, you’re going to end up above that. Above that, a lot of people are price insensitive. Right. Because at that point they aren’t paying, the insurance is paying. So you need to have something that says, hey, if you pick something that’s less expensive than the sort of standard thing that might be covered and save some money for you and the insurer, you should share in that savings. So you need some a hook that says even for pretty expensive stuff, if you shop and find something that looks like it’ll be just as good but less pricey, you get to save some of it yourself and you get the benefit from it.

Bill Frist:                       Is that reference based product.

James Capretta:            It’s called reference based pricing and it’s been tested in a couple of very specific examples and shown to work and I don’t think we’ll be surprised. They did it in California for everybody always goes to the same obviously joint replacement is kind of an easy one to pick. They did it for joint replacements and because it’s so routine and common, they have a very large number of people doing it. And they found that when they did reference pricing, which basically means that insurer says, here’s how much we’re going to pay and you want to go to somebody above that you pay out of your own pocket.

Bill Frist:                       You pay more.

James Capretta:            And if you go below it, you can save a little bit. What they found was the orthopedic guys who were above it quickly figured out how to lower their price down to the reference amount.

James Capretta:            So the price competition really did work. And they also found, of course, the consumers migrated instantly towards something where they didn’t have to pay anything out of their own pocket. So it does work, but it’s something you’ve got to kind of design and put into the system.

Bill Frist:                       And is that from a policy standpoint, again, being here in Washington, is that easy to do or is it hard to do it?

James Capretta:            I think it’s hard to do, but necessary. I’ve had a lot of people comment on my paper and say, golly, this seems like it goes right at some of the insurance design systems that are out there. You’re going to have the federal government telling insurers what they have to do here. And the answer there is, look, I think for those of us who are on the side of allowing market incentives, trying to have some private initiative in the health system, we have to also grapple with the fact that it isn’t probably going to work very well unless the government helps and provides some guard rails to steer it a little bit in the right direction.

James Capretta:            And I think one of those things that needs to be done is to try to have our private insurance system make it so that people do have good incentives and the ability to find savings for individual services when they can. So I’m not too against regulating the insurers in this way. Yeah.

Bill Frist:                       Yeah. So we have the prices. I’m thinking going back to sort of basic consumer producer relationship. You have the prices and you described a sort of bundled entity. Light can be hip replacement, can be cardiac surgery, it could be transplant, could be, you haven’t mentioned quality at all. And how does that flow from an economist standpoint, how does that flow into these equations? Because you basically said they’re all the same and in truth they’re not all the same.

James Capretta:            Right.

Bill Frist:                       I know some very poor cardiac surgeries they have poor outcome. And how does the economist plugin quality?

James Capretta:            Thank you for that question because of course you’re saving me from getting a lot of criticism from the providers. Let me clarify a little bit here. First of all, when I said that everything’s the same, I meant to say that the government gets involved by standardizing what is supposed to happen to the patient clinically. So you say you do a knee replacement you got to make sure you get the right device, you do this kind of procedure, you provide the anesthesia, you provide some post surgery therapy for the patient.

James Capretta:            And so it’s not saying that everybody’s going to do it as well. Okay. I do agree totally that value in healthcare of course, is both right? It’s the price and the quality. It’s making sure people get good value for what they’re spending. And the quality piece is critical. And so there are tools and they’re beginning, but they’re not, as I said, these tools are still catching up. There are tools that are combining price comparison with also some fairly crude, but hopefully getting better metrics of how these providers measure up against each other on quality scores. And so getting those two together on that same app, so to speak, right, is going to be critical. Right? Yeah. I can get a low price, but boy-

Bill Frist:                       Is that getting easier to do because we have more data or more available data and better technology?

James Capretta:            It’s a lot easier. But I got to say in some way the flood of data is so much, there’s this little bit of overwhelmed aspect to it. So the technology is still catching up, but they’re trying and working hard. Many companies are working hard at taking this mass of information and trying to boil it down to something that they understand, believe until the regulator community, but also the consumer community and say, how can we understand all this and make sense of it? And then point it down to a score that says when you go to this facility or this system and they have 10 different physicians and get your knee done, here’s how well they’ve done on an aggregate basis. And I think that’s the kind of thing that could help a consumer. Right? And so they’re getting close but not there yet. It’s a flood data they’re getting.

Bill Frist:                       Yeah. It’s fascinating. And again, your paper’s tremendous. And then for our listeners, we’ll get the reference for them on the website. This morning I was at the United States Capitol, went over to my old office, over my old Majority Leader Office, and then I went to the health and human services and met with the people from the center Medicare, Medicaid, and CMI. And I’ll bet you four people today stopped me and asked, Bill, you are around here, or Senator Frist you were around here and you did a lot of health policy while you’re here. What do you think of Medicare for all? And so that’s four different people. So I’m going to just flip it to you. You live here, you participated in a fantastic policy Institute three years ago. It was four years ago, three years ago. Really was not a part of the political narrative and it is now and it will be regardless of the elections. But where do you start when people ask you about Medicare for all?

James Capretta:            Yeah, I think I start with a little bit of sympathy for the public in a sense. I am against the proposal, and I’ll talk about that in a second, but I think we have to understand in the United States that we have a great health system and we have the best, when you think of the institutions we have around our country they are jewels, right? That you don’t want to lose. And we have the best trained physician workforce. We have cutting edge research and innovation going on. A lot of people trying to improve the health of the American public in the right way. So all of that is just absolutely fantastic. But underneath it, there is a level of dysfunction and pressure on people that makes them look to other countries and say, boy they’re awfully healthy in Germany and they don’t deal with all of our dysfunction.

James Capretta:            So you think to yourself, yeah I mean, I’m sympathetic to people’s impulse to want to do it. But on the other hand, I think that it’s a little bit simplistic. And the impulse there is to say that government price setting, which is really the heart of Medicare for all that is the government deciding what it’s going to pay for individual services all on Medicare. That’s really the essence of it. Because that’s the only way they get the costs under control and make it simple for everybody is by having the government set the prices. I think the idea that that is going to kind of solve all our problems in United States and come without controversy is really just a pipe dream. And so the heart of the proposal is unrealistic. And then my view in that regard, hospitals couldn’t survive on Medicare rates.

James Capretta:            There’d be closures all over the country, the physician community could revolt. It would really be a danger to further innovation and adaptation. So my hope is that in the United States we could say to ourselves our system is got challenges, but we’re on the cusp. If we can do the right things of sort of understanding that we have a fantastic system that could be even better for everyone if you just did the right thing. And we don’t have to go down this road that has some political risk associated with really sort of a two or three decade downgrading of the quality.

Bill Frist:                       It happened after I was here in Washington, but the Affordable Care Act, the move from Obamacare where we were told or what was billed is it is an access bill, we’ll have universal care. And that was the thesis. Where did it go wrong and what does it teach us about either being careful as we move forward, not just in these next elections but the next decade?

James Capretta:            Yeah. Well it’s interesting. I think that’s a very important point because the democratic party is, I think they’re just very fixated on the words universal coverage. Right. And president Obama really sold the Affordable Care Act as being, if not the full answer, a very large part of the answer toward universal coverage. And the current debate is in a sense almost saying, well that may be, it didn’t, wasn’t the case and we have to do something even bigger. Right? And I think that’s a shame because of course the Affordable Care Act has, I think some problems associated with it. But on the other hand, if you look at the number of uninsured in the country, 32 million or so, two thirds of them are covered by the Affordable Care Act. They just haven’t signed up with it yet. So if I think if most Americans heard that they might think to themselves, does that mean we don’t need to do Medicare for all, we just need to sign up the people for the coverage they already have.

James Capretta:            They can be on Medicaid, they could be in an employer plan, they could be in the exchanges with a lot of subsidized care. So if I were advising people on this thing and I tried to doing my writing, I’d say maybe step back from this kind of all or nothing debate and say, yeah, the Affordable Care Act had problems but why don’t we just take some of the holes that are there and patch them up and get people into coverage they probably already are eligible for before we create a whole new program to take the whole country in a new direction. I think that’s part of the question that needs to be put there. Now back to their original point that what went wrong with the Affordable Care Act? I think the reason why it’s still a little bit unpopular politically is back to this deductible question and how they handle the individual market. There’s an awful lot of people who are healthy in the individual market pre 2010. They were there for any number of different reasons and their premiums and their coverage got a lot worse.

Bill Frist:                       In the individual market is 15 million people, 20 million?

James Capretta:            It’s about 20 million, about 10 of them in the exchanges now and then a lot of them outside the exchanges now. And before the Affordable Care Act it was basically people that couldn’t get coverage through the employer system for any number of different reasons. They were self employed or they’re on outside that system for any number of different reasons. Buying coverage on their own. If they were healthy, they got a pretty good deal. Now I’m not saying we didn’t need to do something about people with other health problems that need a better system than we did, but when the Affordable Care Act came in, a lot of people said, watch out. All the people that are already there are going to be upset because they’re going to turn around and one or two or three years from now and all of a sudden their premiums are triple and their deductibles tripled and they’re told they don’t have any more choice.

James Capretta:            So that’s basically what happened. And the word about that spread, and a lot of people said this ACA, Obamacare thing didn’t work out for me. Now it helped a lot of other people, but it didn’t help that population. So I think that’s where some of the political problems still resides and in the United States, like everything else, if you don’t do something on a bipartisan basis, that kind of problem gets ignored by one party rather than the other. I think if they’d done it more bi-partisan, that problem might have been addressed a little bit better and then maybe some of the stability would have been there politically too.

Bill Frist:                       That’s a great point having been in my past in politics, if you look at the other major social programs, Medicare, social security, Medicaid, all of them ended up being bi-partisan. And this was the first major piece of social legislation that was strictly partisan. And then when things didn’t go well or bumpy has anything’s going to be, you have people’s hand, Oh, I didn’t vote for it. And the people who voted for it started scratching their head. So I think the big lesson, and it’s a real lesson, I think going forward as we move into whether it’s transformation or a form, ribbon, disruptive policies, having some element of bipartisan and as a former leader you can always get it. There are always ways to get it. And again, that’s sort of my biggest criticism is as we look forward. But more importantly as we go looking ahead we need to at least check that in.

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Bill Frist:                       What about the elections? People will be listening to this probably into the elections and after. So you got to be very careful what you say because there’ll be able to-

James Capretta:            I’ll agree, right.

Bill Frist:                       That’s right. The whole nature of this means that communication, but how do you bank where we are? You mentioned it earlier, that health care is rising back again in the last elections. It ended up even though going into it, we didn’t think it would, but it ended up in the exit polls showing it was a very important issue after that there was a lot of fatigue that all of a sudden now you see healthcare coming higher and higher. What’s that going to mean for the elections?

James Capretta:            Well, I think the reason it’s there, just back to our earlier point, is that a lot of ways a pocketbook issue for Americans. It’s a proxy for economic stress, a little bit concerned about their own family finances saying, golly, this is a problem for me. I’m worried about my kids’ education. I’m worried about paying for college. I’m worried about healthcare, those are the-

Bill Frist:                       The more it costs spending is you have an access [inaudible 00:24:16].

James Capretta:            I think it’s very much Senator that it’s really about people’s financial pressure and they’d like the government to do some of that. I think that’s really what’s going on. So the response then is what to do about it. And I think the democratic party in its primaries and the debates that are being ongoing now will be going into next year.

James Capretta:            They’re trying to address it and I think they may have part of an answer that they can take to the electorate, but in some ways they’re also maybe making it bigger than the electorate wants. Right. So I think as we get along in the election, my guess is both parties will start to zero in more and more on just addressing that middle-class, maybe slightly lower middle class concerned too about cost pressure and what to do about which is my prescription drugs is a big factor for both parties. Which is why you hear the president and his people as well as people in the democratic party talking about lowering premiums and-

Bill Frist:                       Surprise bill, medical.

James Capretta:            Surprise billing. So I think all of that is likely to become a concern for both parties trying to answer that sort of pocketbook part of the question in healthcare.

Bill Frist:                       From all your sort of many years both writing, studying, doing analysis where we are today. A totally unfair question really, but is there one, if you had to kind of put one priority issue or pick one of the more important ones that you think could be done, shouldn’t be done that would impact the trajectory of health or health care in the future, and think in terms of a policy, what would it be?

James Capretta:            I do think I, I don’t mean to keep harping on this. I do think if we’re going to have a mixed public private system where there’s a lot of public role, but also still a big private role, we got to get the private side a little bit better than it is. And I think the big part of it, there’s a number of things that have to be done, but you only gave me one. So I said the one I think I do something big on price transparency to help the consumer more easily see their options and have the government, the federal government. I know a lot of our consumers that don’t like me to say that, but I-

Bill Frist:                       People don’t, I know you do and I do but a lot of people say markets just don’t work in health. They work in financial institutions, they work in other industry, other sectors, but without sort of both a willing purchaser by a relationship and a knowledgeable to where the train can be made. And then the lack of transparency in pricing. Is that why it’s becoming so important to people. The why the people are feeling it. But markets, they can’t work if you don’t have price transparency. So why weren’t you writing about it four years ago? Why wasn’t it out there?

James Capretta:            Exactly, well, in some ways we all thought, we all thought, and I all plead guilty to this for sure, that as we got more into HSA and as we raise deductibles, we thought in expected the market response to be a little bit better in terms of making it easy for the consumer. We thought that the suppliers, frankly the health systems, the physician can be-

Bill Frist:                       Everybody throughout.

James Capretta:            … The entrepreneur are out there. The breakaway guy who wanted to be disruptive might say, hey, I got a good deal for your consumers, come to my clinic and I can do what they’re charging you eight times what I’m going to charge you for this and be a little bit more entrepreneurial about it.

James Capretta:            And I thought more that was going to happen than it has. And I think there’s a couple of things going on here. One is that, why do people often say markets don’t work in healthcare. There is one thing conservatives have to grapple with, which is that when you see your, you have a lot of power. Your patients come to you, they don’t know anything about how the heart works. Right? And so they’re trusting you. They’re putting their life in your hands. And that’s why there’s so much ethical responsibility on the physician community too. And they take it so seriously. They know that. So there is this very important information gap between the patient and the provider.

James Capretta:            Then you can’t get around and they’re going to have to trust that physician to steer them.

Bill Frist:                       Yeah. All that’s changing.

James Capretta:            It’s changing, throughout the web.

Bill Frist:                       With the Internet and access and all [inaudible 00:28:26].

James Capretta:            I know they’re questioning, but I mean, when it gets serious, when it gets serious, when it gets cancer, when it gets to a major surgery, there’s no way somebody can research all that on the Internet.

Bill Frist:                       Yeah, that’s right.

James Capretta:            So what I’m saying is that there’s this trust and information imbalance that does impair the ability of the consumer to act as a sort of an independent agent in a lot of cases.

James Capretta:            Having said that, the government can help a lot through this thing I keep talking about, which is trying to standardize it a little bit. Yeah. You don’t need to know every aspect of how they go about doing a hip replacement. But if we tell you that we’ve standardized the protocols more or less and said, hey you’re going to get the same clinical experience, more or less, the quality could be different, but they’re supposed to be doing the same thing to you from this orthopedic unit versus this orthopedic unit.

James Capretta:            You could start to then compare the price more easily because you’re going to know, hey, they’re supposed to give me the same thing. Right. So I think that’s a big step. Something that sort of takes the uncertainty away from the consumer that, hey, am I going to get the same thing from this one versus this one? And I’m a big part of that is some regulatory intervention to try to make it easy for them. I know a lot of conservatives don’t like that, but I think we’ve had enough history where we’re 15 years past HSAs and they’re helping a little bit, but not as much as we’d like.

Bill Frist:                       Yeah. And that’s where there’s intersection of policy, sort of Venn diagram and health and healthcare and what we learn and we need to apply and the policy is going to be important to give the framework, especially in imperfect markets where information is not really equal, the pricing is still messy because of the lack of transparency. Even though we’re moving in that direction and outcomes are difficult in terms of the clinical world of really saying what’s a good outcome, what’s a bad outcome?

James Capretta:            Sometimes you don’t know for five years.

Bill Frist:                       Yeah, you don’t know which it’s an investment. And then on the prevention side is really a challenge because you intervene and that may be 10 year horizon. All of what you’re challenging. Let me close with again more personal thing in your career. A fascinating career that I outlined earlier in sort of the buildup to our interview. Was there a pivotal moment that affected your trajectory? And I say this because a lot of people listening are people who have aspirations to do certain things and probably in the health healthcare world and might be in the economics world, the policy world, the writing world, will be a clinician. In your own history was there a single moment or was there a incident that sort of changed your trajectory?

James Capretta:            Yeah, well I’d say that I didn’t plan to get involved in healthcare policy at all. Honestly, when I came to Washington, like a lot of young people when they come to Washington, I was just looking to get employed and find my way into the policy world. I was interested in public policy and I worked at first job at the office of management and budget as a career civil servant. And my portfolio wasn’t health, it was income maintenance. I did sort of social security and social welfare programs, but then I got a call from a former colleague and he had worked on the Hill for a committee you served on, the Senate budget committee under Senator Pete Domenici.

Bill Frist:                       Yes, me too. Yeah.

James Capretta:            And I got a call from him saying he was leaving and he wanted to know if I’d like to replace him and his portfolio included health. And at that time I looked at that and I thought, I wonder and that all you could see was that this health thing was like dominating every discussion, even back in 1990 and so I did it. And it also is less than in low barriers to entry.

Bill Frist:                       You got a phone call in.

James Capretta:            I didn’t know a single thing.

Bill Frist:                       And then you had the experience.

James Capretta:            I didn’t know a single thing about healthcare. And I started reading and working and thinking and they threw a lot of stuff at me and I had to learn as fast as I could and did my best to try to get up to speed. And all these years later I’m still working at it.

Bill Frist:                       Started with a phone call.

James Capretta:            Started with a phone call yeah. So sometimes things like that happen, you just never know when the opportunity will come.

Bill Frist:                       IN closing are you optimistic, you’ve seen so much in the time has been dramatic. You’ve been at it for almost 30 years and so you’ve seen from the Clinton years and really every administration and then you’ve seen the attempts with the Obama administration and now you have the Trump administration. Still very interested in value based sort of approach, which means looking at outcomes and prices on the trajectory of that. Are you optimistic or pessimistic or is it palm just too, too hard. You talked about your own learnings with the health savings accounts. Is it just too hard?

James Capretta:            I don’t know. I mean I guess I’d say Senator, I’m pretty optimistic mainly because of our, and this sounds a little bit pie in the sky. Mainly because our constitutional system that in America we do have great accountability when things aren’t going well people complain, you have the press look into it, they get the vote and then we have a political system. Our structure is set up by our founders that forces people to compromise most of the time. And find a way forward to solve problems. So that system is coming under pressure as our politics becomes more polarized. But I think all in all it’s still pointing toward having to deal with real world on the ground problems in practical ways and more than likely the extremes of solutions aren’t going to make it. That is going to have to be building on what we have, trying to make it better, taking step by step as we always have. And I’d say the other part that makes me optimistic is the innovation, the entrepreneurial aspect of our health system.

James Capretta:            People trying to find better ways of taking care of people. There’s a lot of activity, better than anybody in that space and not all of it’s paying off yet. But I still believe there is big payoffs to come.

Bill Frist:                       Jim. Thank you.

James Capretta:            You are welcome.

Bill Frist:                       Thanks for spending time with me.

James Capretta:            Thank you.

Bill Frist:                       And our podcast listeners and viewers today and appreciate all you’ve done and you contribute in a very substantive way in terms of the papers, the thought leadership working at AEI, which is a great forum for discussion and both your intellect and the practical pragmatic proposals that you put on the table are a huge contribution. Thanks a million for being with us.

James Capretta:            Thank you.

Bill Frist:                       Thank you.

James Capretta:            Senator I really appreciate you having me. Thanks.

Bill Frist:                       This episode of A Second Opinion was produced by Todd Slusser, The Modus Creative Group and SnapShot Interactive. You can subscribe to A Second Opinion on Apple Podcasts, Spotify or wherever you are listening right now.

Bill Frist:                       You can also watch our interviews on YouTube or on our website and be sure to rate and review A Second Opinion so we can continue to bring you great content. You can get more information about this show, it’s guests and sponsors at asecondopinionpodcast.com. And be sure to join us for our next episode where I sit down with Paul Fipps, the chief digital officer of Under Armour and Gyre Renwick, vice president of Lyft business to call it the Google, Alexa and the future of voice activated healthcare. Second Opinion Broadcast from Nashville, Tennessee, the nation’s Silicon Valley of health services, where we engage at the intersection of policy, medicine, and innovation.