Episode 3

What May Future Healthcare Look Like?

Transcript

Rick Sindt

Tim, thank you for joining us today, once again. 
 
Tim Classen

Sure 
 
Rick Sindt

I’d really like to start with establishing some context of what you've been observing over the past 15 months to two years, during the pandemic, before we get into talking about where you imagine our post-pandemic life might go. So, let's take a few moments to talk about what you've seen and what you've been paying attention to because everyone's perspective is different. What have you been noticing? 
 
Tim Classen

Absolutely, thanks for taking the time to meet with me today, Rick, and welcome to everyone out there who is listening to this. We had a podcast recording in about April of 2020 about what we expected to happen or the concerns we had at the beginning of the pandemic. So, now–a bit over a year later–we can reflect a bit. I think there was obviously a lot of hope for this summer, with vaccines widely available, although we still have concerns, especially in certain states, in terms of the rate of people getting vaccinated but yeah to reflect a little bit on what I've taken away, or learned, or thought about in the last 15 months... I study mental health, I study suicide, I study substance abuse and opioid overdoses and a lot of the discussion publicly has been around concerns related to people's mental health during the pandemic and during isolation, certainly [because of] the lockdown, [and] given the social isolation people were experiencing. 
 
There were a lot of concerns–and they varied across the population–a lot of attention has been placed on kids not going to school and the socialization process we normally think about [when] kids [are] able to interact with each other, learning from each other, in a more dynamic environment. There are big concerns about the loss of that. 
 
There are also concerns about bullying in schools and some of the more negative things were not happening; like drug use and initiation by peer groups and, certainly, we did miss out on some of those things. 
 
So, for the population of younger kids and adolescents, I think [there are] a lot of the concerns around the lack of social interactions in schools and, obviously, how that affected learning. 
 
For the older the working age population, the labor market took a big hit. Unemployment spiked again to 10% in a really rapid manner. It was not like the great recession where there was slow build into a terrible labor market, this was a very rapid. Ascension from 4% to 10% unemployment basically overnight last year, and so a lot of people lost their jobs. A lot of people had a lot of uncertainty around their employment status [wondering] when [or if] their jobs will come back with more vaccines be available. 
 
We had an especially contentious election last year that caused a lot of people a lot of anxiety on both sides of the political aisle. 
 
All those things added up to a lot of concerns about how people were dealing with their mental health when they didn't have the usual social networks in which to engage with. Discussions and interactions that can be productive, such as going out to dinner, became impossible. You really couldn't go out to dinner. You couldn't meet in person, for the most part, and so certainly zoom became a substitute for almost all of our interactions with other people. This environment has some benefits, I saw people over video that I didn't see in a long time: Grad school friends and acquaintances, but obviously it's exhausting. It is isolating. It doesn't have that same feeling of going out and interacting with people you missed during that time. 
 
The way that affects people's mental health raised real concerns along the two dimensions that i'm most interested in. That is: suicide and opioid overdoses. 
 
The initial data I've seen for opioid overdoses is not very favorable. I think it will show that last year there was an increase in substance abuse and an increase in fatal overdoses.  
 
Fentanyl is everywhere in the country now. If you're not familiar, Fentanyl is an opioid that is highly toxic. It's about 100 times as strong as morphine. Getting a dose of that, even a small amount, can be fatal quite quickly. We have a Fentanyl problem that didn't go away and [instead it] spread to the whole country. It was kind of an East coast thing maybe five years ago; now, the whole country has access to Fentanyl.  
 
The isolation, the desperation, the desolation that comes from being in a lockdown led 
more people to abuse substances in an unfortunate way.  
 
So, on the drug overdose front, I think last year’s is data is going to look worse than the previous years. 2017 and 2018 numbers were looking a little bit better. 2019 they up ticked again, and I think 2020 we're going to see another uptick–unfortunately–mostly related to Fentanyl overdoses from illicit drug use. 
 
On the suicide front, I think we've actually seen more encouraging data. 
 
A lot of stories about local areas having increased in rates of suicide, but those were often counting areas that had 11 people commit suicide, instead of eight the previous year in 2019. So, this was promoted as a large increase in rates of suicide, but the better data I've seen and have been able to access actually shows either flat or declining rates of suicide in a lot of areas. 
 
The concern over increased rates of suicide due to isolation has not actually come to pass, and  to me that is encouraging. It makes me think about what it was that was protective or didn't result in as maybe as many suicides as we feared due to mental health and isolation. An explanation I heard that I find somewhat convincing is the idea of we were going through a collective trauma. 
 
Obviously, there were differences. In terms of what it looked like outside your house depending on where you lived in the country. But the risk of COVID was a worldwide phenomenon, the whole world at different times faced an incredible risk of this incredibly fatal virus. It infected certain populations in different ways but that risk–it was 7 billion of us going through that kind of risk at one time–and in this country 330 million of us experiencing covid in some way. It was a collective problem. It wasn't like the factory shut down in our town and our town is suffering, it was across the country, a risk that we all faced, and so that might have been protective to feel like we're going through this together. 
 
I've written papers on it before; about how elections affect rates of suicide. Typically, prior to elections rates of suicide go down because of the collective aspect to elections. Regardless of how you feel about the candidates, there's a discussion about our country, there's a discussion about where we're headed.  
 
Obviously, we're becoming more splintered in terms of preferences over candidates, but they're still happening and we can see a lot of people believe like I do. 75 million people voted one way and 80 million people went the other way and so you are able to feel like there's at least 75 million people out there that think kind of like I do or 80 million people that think kind of like I do. That typically has been found to have been protective [qualities] or reduce rates of suicide prior to elections. 
 
So, certainly the election was going on but also this collective event that you couldn't avoid: COVID.  
 
It wasn't like it just hit Chicago and it didn't really hit other parts of the country, so I think that might have some explanatory power in terms of why rates of suicide  didn't increase. If they didn't increase at all that's really encouraging. If they actually decreased that might be one potential explanation. The initial data that i've seen is not as dire about suicide as we feared and so that's encouraging that rates didn't go up. 
 
I also think about healthcare markets, I think about and work in healthcare a lot. 
 
Obviously, a lot of the attention of the last 15+ months has been about how the healthcare industry was affected by COVID. And with labor markets, there were a lot of workers were exposed to COVID and, unfortunately, we've lost a sizable number of healthcare workers because of their exposure to the virus. And that's tragic. It will affect things for a long time. I've been wondering about how that will affect–to talk a little bit about in the future–how is that going to affect healthcare as a field in terms of attracting new talent into that labor market. 
 
Do people, fear health care because of the potential risks associated with dealing in an industry where there's that kind of a virus or do people say, “wow, those vaccines were produced so rapidly, and we were able to roll out the vaccines there's so many people and get back to life so much more quickly than expected”? 
 
This is an incredible industry that can change people's lives in such a profound way and the people that got saved. ICUs were full but they provided a treatment that allowed people to stay alive, even with the tremendous number of losses–now over [700,000] people have died from COVID in this country alone. This could be appealing to some people. Certainly, the pharmaceutical industry got a big win with Johnson & Johnson, Pfizer, and Moderna getting the vaccines produce so quickly. Obviously with big government support for it but [the fact] that industry was able to produce something that allowed us to get back to some semblance of the social interactions we are now enjoying has tremendous value. And that came from the government working with pharmaceutical companies to produce this thing. The value of those vaccines alone, we can think of in probably trillions of dollars.  
 
But the trauma of that industry, people working as ICU nurses, the doctors, the hospital staff that we're all exposed to those risks. Then the long-term COVID cases, those with long-haul COVID side effects that we're now hearing more about. That's going to be a challenge going forward and how people deal with that will be something to keep our eye on. 
 
Rick Sindt

I've been thinking on my own a little bit about the healthcare labor force and how I've heard that enrollment in Medical School is way up, but–when you're talking about how the industry is going to be affected–I was thinking well we're going to have a lot of people that want to be doctors and we're not going to have a lot of people that want to be aides. 
 
Tim Classen

And I think that's an evolving demand and supply. Healthcare is evolving pretty rapidly. Medical School is still quite attractive; we get about two and a half applicants for every seat available. So, we get over 50,000 people applying for about 22,000 empty slot and close to 10,000 D.O. slots, doctors of osteopathy, so we're producing about 32,000 to 33,000 new doctors a year domestically. 
  
We're getting quite a few applicants for those slots and [those positions are] financially attractive. What you can do to people as a doctor–to save their lives, improve lives–is an incredible gift that those workers get to receive as part of their occupation.  
 
With skilled nursing, with physician assistants there's still a lot that makes a relatively attractive market and doesn't take as much time to get trained up as a doctor... becoming a doctor can be 10 years once you get through a postdoc and fellowship, but the [other positions have a] more rapid turnaround, and we need more labor supply. Typically, PAs and Skilled Nursing Practitioners are a way to get [into the field] in three years or four years. Certainly, the other skilled health care services are going to remain an attractive market but there are concerns around burnout.  

 
There was already concern about doctor burnout. Suicide rates among doctors were concerned, prior to the pandemic [because of] the stress that they experience. Now, the potential exposure to the virus, the environment in which they're working [having] to put on PPE on a daily basis–those kinds of things are not going to help to burn out situation that was already present. 
 
In this workforce, [that] certainly raises some concerns about doctors in the second half of their careers. A lot of times they have very different views on healthcare than the new M.D.s. [The industry is] changing for a variety of reasons, but certainly COVID inflicted some trauma on the whole industry in a certain way. 
 
Rick Sindt 

Yeah, that makes a lot of sense. When you put all these observations together, and you look into your imaginary crystal ball–which I know economist don't necessarily like to do– what predictions are you seeing for the future? Whether that be either something that feels really data driven but cynical to you, or a trend that you hope that we get to follow. 
 
Tim Classen

Yeah, as I've told you economists like to explain why the past happen the way it did and asking us what the future is going to look like is a much broader exercise for economists. So, I'll preface any comments I make about what the future is going to look like based on that. 
 
One thing we do know is that Medicare is going to grow. So, Medicare is the program that provides health insurance for the 65 [and older] population and also for end stage renal disease; those with kidney failure are covered by Medicare. Both those populations are growing. With diabetes and other issues growing as health concerns, end stage renal disease is going to become more common in the population and that's going to increase the number of people on Medicare. [Additionally], the 65 plus population is increasing, due to the baby boomers and older people living longer. That's a good thing! It's good that people can make it. People who can make it to 65 are more likely to make it to 85 than they ever have been. 
 
We've heard about increasing mortality and decreasing longevity. That's really due to the suicide and opioid crisis so that's actually the pre-Medicare, the 45 to 65 year old population, is why longevity might be decreasing in certain populations. But among those making it to 65, Medicare as a source of health insurance it's not always ideal. It is global, in the sense that almost everyone who reaches age 65 gets covered by Medicare. We have a lot of problems in the 18 to 65 year old health insurance population. A lot of people get their insurance with their employer, others on the health insurance exchanges that were set up as part of the ACA in 2014–the Affordable Care Act or Obamacare, and then people get Medicaid [which is] for low income or the disabled populations. A lot of people get Medicaid so it's a lot more disjointed in terms of what health insurance looks like for that population, but for the 65 plus population they get Medicare but even Medicare actually looks quite different. One thing that's happened a lot in the last decade is people have been buying private Medicare Advantage plans. It's actually private health insurance companies, covering people for their Medicare benefits. Now we're getting close to about 40% of the 65 million or so Medicare beneficiaries [being] enrolled. A lot of people are getting what we think of as public insurance [but they] are actually enrolled in private health insurance plan. I would foresee that's going to keep growing. Medicare Advantage has been pretty popular.  
 
When the Affordable Care Act came around in 2014, they were going to cut the rates that were paid to these private health insurance plans to cover Medicare beneficiaries. Obviously, Humana and the other private insurance said, “No I don't think we'll take a cut. We’ll actually take a little increase in what you're paying us,” and that's continued. A lot of the outcomes are pretty favorable there was a lot of concern that these private plans were attracting the best health risks pools of healthy 65 to 70 year olds that weren't used to health care, but they developed as more comprehensive and better continuity of care and are providing potentially better health insurance benefits at an equal or lower cost and that's an ideal situation. To be able to improve the health of the Medicare population, while providing services at a lower cost. 
 
The concern would be if they're providing the same benefits as traditional Medicare at a higher cost and about a decade ago that's more what we were seeing in the data. So, I would predict that Medicare Advantage is going to expand. 
 
The number of Medicare enrollees we know is going to expand simply based on population trends, we have a lot more people joining Medicare than exiting. [This is creating] a fiscal crisis, a fiscal situation. The public payments for Medicare that what we pay is going to rapidly get over a trillion dollars quite soon. It's going to take up 20% of the federal government budget. We all need to be aware of that, think about that and pay attention to it, and [think about how we are going to pay for it.] Right now, 2.9% of every dollar you earn goes to a Medicare Trust Fund. That only pays for the hospital benefits, Medicare drugs and physician services are covered separately and those come out of the basic federal budget. There's no taxes associated with that and so, just as an anecdote, the latest FDA concern that has been raised, [after] the big vaccine win, was almost immediately after the FDA approved drug for Alzheimer's called Aduhelm that's raised real concerns because it's tremendously expensive, about $56,000 for a year of the treatment and it doesn't cure Alzheimer's! It potentially treats it in a way that improves the people's lives, but there is [even] a lot of debate over how clinically effective it is. If even half of the Medicare beneficiaries who have Alzheimer’s got access to Aduhelm the cost of that would be over $100 billion a year. Which is about what Medicare spends on [all prescription] drugs at this point.  
 
So, that is my crystal ball next to the current fly in the ointment for Medicare spending is. 
 
Hospital benefits, Inpatient hospital services–which we’re thankfully actually moving toward outpatient systems–so for the Medicare taxes go just for those inpatient hospital stays and physician services. In the meantime, the drugs that come out of general spending is growing much more rapidly than inpatient spending. How we finance that is going to affect all of our paychecks for the rest of our careers, and so I think that's an essential piece that we need to talk about. And have a real discussion on what is Medicare covering and how are we paying for it so. I realized that's a bit esoteric and maybe a bit narrow but Medicare is such a big payer within healthcare that they do affect so much of what private insurers do in terms of their payments for health care. 
 
We're down to about 30 million without insurance out of our population of 330 million. So, we are below 10% of people without insurance. The concern has been in the last decade, increasing deductibles within the health insurance market. Those of us lucky enough to have employer-provided health insurance, in a lot of cases that comes with a deductible of over $2,000 for an individual plan, or a family plan with a deductible about $5,000 that's becoming much more common, especially in smaller firms with smaller risk pools. If you're facing a $5,000 deductible, that doesn't really feel like much health insurance because unless you end up with an Inpatient hospitalization all you're spending on healthcare is going to still come out of pocket–at least at the negotiated rates that insurers have provided–but it's going to come out of pocket or, at best, maybe you have a health savings account or FLEX account that you can draw upon on the before-tax basis to pay for health care. But the insurance what we think of as insurance the usual 80% insurance pays 20% I pay that doesn't kick in until after the deductible.  
 
It'll be interesting [to watch] as the labor market corrects. We were down to 4% unemployment rate before the pandemic in late 2019. Insurance was based on what we think of as even below its natural rate of 5%, it was down to 4% unemployment. That's great because a tightened labor market typically results in more generous benefits from employers trying to attract talent. What we saw during the great recession was a very loose labor market of 10% unemployment allowed employers to impose on workers very high deductibles. A tighter labor market of 4% unemployment, you might think the benefits we're going to become more generous. Maybe reducing those deductibles; I think we saw at least them flattening out 
and beginning to decline. Now we have a very disruptive last 15 months in the labor market. Once that settles out and, hopefully, we get back to 4% unemployment rate, maybe we can get more reasonable deductibles because a lot of people avoid a lot of necessary care because of high deductibles. 
 
If you actually see the list price for a doctor visit of $300 for a 15-minute visit you're much less likely to do that than when you see it has a $30 copay. 30 bucks for waiting in the waiting room for 30 minutes and I'll get to see the doctor for 15 minutes and they're a trained professional, I feel comfortable, I'll pay 30 bucks for that. But, when it is 300 bucks plus the time cost that becomes much less attractive and so, unfortunately, a lot of people avoid a lot of beneficial care and that has a real cost in terms of longer-term health detriments. Because of this last decade of higher deductibles, I think we might see in the future increasing health needs among certain populations, specifically workers in smaller firms. 
 
What if you're 55 and had been having a high deductible and avoiding care for a while? You get to Medicare and then Medicare has to make up for that cost of care that results from you having some health conditions that could have been more efficiently treated a decade ago. That's another concern of these high deductible plans. 
 
About a third of employer-based plans are now what we consider high deductible health plans and a lot of those do not have tax-deferred health savings accounts tied to them and those of us lucky enough to have FSAs and HSAs with generous employer plans feel like “what's the problem?” But so much of our labor force is exposed and tremendously high deductibles and if you have a chronic condition that's basically $4000 to $5000 a year you've got to set aside for out-of-pocket health spending. If you're making $50,000 a year that's a tremendous burden on people's budgets. So that would be my hope–I'm supposed to be hopeful and there's not always a lot of hope in healthcare–but my hope is that a better labor market might push deductibles back down to a more reasonable level. 
 
We need to pay for high-value care, we need to cover well high-value care, and quit paying for low value care. That's kind of the simplest answer. In healthcare it's always quit paying for that stuff that doesn't really provide better health to people and pay more–reducing the cost to co-insurance or the cost-sharing–to those things that work really well; even pay people to do stuff! I mean now this doesn't sound so farfetched. States are running lotteries to get people vaccinated.  
 
This idea that we should pay people to do things in the benefit of their own health or the population health, the public health, five years ago would get you laughed out of the room. Now, some people are getting paid a lot of money to get vaccinated. It's random and maybe we should have a targeted approach to give everyone $100 for getting vaccinated. We at least made the price zero and tried to effectively communicate that, but even that was fraught with a lot of misinformation and people confused about what the price of getting vaccinated would be. It was zero out-of-pocket costs to the patient but a lot of people weren't aware of that, especially initially. Hopefully now everyone understands there's no cost. Now we have seen incentives for certain behaviors. So, that might open up some things.  
 
I think Telehealth, obviously we're going to see more of now, for mental health care, certainly in rural areas things for which you had to travel a longer distance. Certain kinds of healthcare are pretty amenable to talking to people over Zoom, FaceTime, or on the phone and for a long time payers like Medicare and private insurance didn't want to pay for telehealth. COVID forced our hand and certainly for some services we've adapted really rapidly to allow for telehealth and so that will continue. That will certainly be something going forward that we're going to see. I don't know that it'll expand from the current levels and probably it'll contract a little bit, but certain things are going to stay online like mental health care for rural patients. I would think hopefully those people can get access to care they previous had to drive an hour to get, and so I think that's to be a real benefit for our healthcare system and the health of people in those areas. 
 
Rick Sindt

The big thing I'm hearing, a big theme in your observations, is: Medicare is going to be required to expand but not in the universal health care way that the more liberal people in society would like to see. 
 
Tim Classen

Yeah, progressives have been asking for Medicare-for-All or universal coverage of some sort. It's always important to be careful about what we mean by “universal coverage” versus a “universal health care system” where the provision of healthcare is also publicly provided. Like the UK would have the closest thing we could think about in Western Europe or the US in terms of a system like that, and that would be an extreme situation where all doctors will be government employees. Doctors are not going to tolerate that, providers typically wouldn't tolerate that, hospitals wouldn't. There's a lot of impediments to even moving towards Medicare-for-All or even universal coverage. Universal coverage is something we got closer to with the Affordable Care Act and, to be clear, it hasn't worked always as we hoped exactly but at least 20 million people got coverage from the Affordable Care Act. It has changed things on the provider side, it’s limited insurers profitability–it put caps on insurance profits in the private market on the individual plans, or it's a lot better than it did before–if you had a chronic health condition and we're seeking to buy an individual plan, you couldn't. There was no price even offered and now we've at least allowed some people to get insured on the private market by the exchanges, and so there have been some wins for that. We've moved toward more coverage. We have more coverage now than we did seven years ago when it began, so that is a win. 
 
Moving to everyone on Medicare, there are certain parts of Medicare that I don't want to be on. 
Certain kinds of coverage that isn't attractive, but we are–again, I'm talking from a position of being spoiled with very generous, pretty expensive private health insurance through my employer that's provided on a subsidized plan. 
 
Again, be aware, at Loyola if my premium is only 200 bucks a paycheck and Loyola is kicking in $1,000 a month for my insurance, that's $1,000 of compensation I'm getting in an indirect way through the health insurance that we’re provided on an employer-based plan. So, just to be clear, in the employer-based plan [we all] get a massive subsidy for our health insurance the tune of about $300 billion of foregone tax revenue from employer-based health insurance. That's my aside on that.  
 
So, we're getting more coverage, Medicaid is expanding, about half the states that expand Medicaid in 2014 to the low-income population–we're up to, I believe, 38 I think, we have 11 or 12 left that haven't–There's been discussions that the Federal Government may intercede and just say, “You have to cover these populations” and we will fund it but that was initially the case in 2014. The feds were funding entirely the expansion piece now they're down to about 90-95% funding for the portion of the population that got Medicaid as part of the State expansion.  
 
So, we have increased coverage. The challenges with Medicare-for-All are going to be on the payment side. You look at facilities, like the hospitals, we have in this city–certain of which have very nice facilities, there are these are luxury facilities that we're blessed to have in the city with a tremendously high quality of care with well-compensated providers who are providing the best medicine in the world, I would say. We have certain facilities in this city that are not providing the best medicine in the world, and that is a tragedy. It matters where you live in terms of the quality of healthcare you're going to get. It matters what insurance you have to have access to that health care. But those kinds of facilities are not going to take Medicare payment for all their services. We would have to increase what Medicare is going to pay for those services if we were to say Medicare is going to be your sole payer. 
 
It would give Medicare tremendous market power if they were the only payer. If they covered all 330 million people in this country, that would give them basically monopoly power, what we call monopsony power, they will be the only buyer of health care services in the country. Typically, that allows them to lower the prices they're going to pay for services but providers aren’t going to tolerate that, doctors won't tolerate that, hospitals won't tolerate that, and we've got a 60-story Blue Cross Blue Shield building downtown that would certainly have no value for the company housed within. That's unlikely to be politically feasible–I don't want to base what I'm going to wish for based on politically feasible things–but Medicare-for-All is a bridge too far, politically. So, I think they keep on the goal of universal coverage of some sort. [It] is a worthy goal that will continue to push forward–whether that's expanding Medicaid, making the exchanges function better, if you're above 400% of the poverty line in the exchanges and you see that full premium price it's pretty attractive. If everyone had to pay for their full insurance premium every month, we would have a very different health insurance system. $1,200 a month out of pocket for my health insurance feels very different than $150 a month pre-tax where I'm effectively paying $100 a month out of pocket for my health insurance. 
If I had to write a check or give an electronic debit every month for my family plan of $2,000 a month I would pay a lot more attention to my benefits than when it's pre-tax and subsidized by my employer. Economists for a long time have wanted to blow up the employer-based system. It's regressive, it's distortionary, but I don't foresee that ending. There's about 160 million of us about half the population still get employer-based health insurance to change that dramatically is incredibly disruptive and so my crystal ball would say in 10 years there will still be between 40% and 60% of the population will be employer-based health insurance still. 
 
Rick Sindt

Is there anything you think the pandemic prove to us in the healthcare field–or wherever you want to talk about–that it wasn't working and you would like to see us let go of as we move in to the next phase of life? 
 
Tim Classen

You know what I'd like to let go of is the misinformation, I think. Economists make some assumptions about how markets function, and so in a competitive market, we think that all sides to a transaction have the same information set. Obviously, there are big information asymmetries since healthcare economics started as a discipline 50-odd years ago. The information asymmetry between patients and doctors, between patients and insurers, has been a profound deviation from how markets function. 
 
I think what has become more salient in the last year has been the information sets people are receiving and believing are very different. Based on what news sources you're reading, based on social media. And that could be the efficacy of vaccines, that could be COVID testing, what the effects of COVID are. So, how we interpret that data–we have more data at our disposal than we’ve ever had, obviously. Every day more data is produced than existed in our whole history until about 10 years ago–we have so much data, so much information is coming out and available. There is a tremendous amount we can access–patient records and things like that in healthcare are still very hard to get your hands on–but the prevalent rates of COVID, we can see them on a daily basis, we can see in the city of Chicago how many tests were performed on a daily basis, the positivity rate, we got that real time data, we have access to that. 
 
And in some ways that's objective, right? It's not perfect data, obviously, a lot of people aren't getting tested daily and what a positive test connotes for people's health we don't really know that, but one of my hopes, is that people become more accepting of science and [understand] there is objective data out there that isn’t twisted by statisticians. The disbelief in data and science to me was one of the most discouraging parts of the last 15 months. That people would believe with certainty things that were verifiably untrue that is a difficult situation. From the healthcare–sure there is skepticism towards healthcare for valid reasons in certain circles and certain populations that don't trust healthcare; that has been a challenge that there have been improvements made over the last 50 to a hundred years, but still that trust and healthcare is something that has to be developed. 
 
There's a valid reason why we're still having little rates of vaccination in certain populations, in certain geographical areas. I don't know how you do that, because if you're–I am what now 46, some of my beliefs have gotten hardened, some of them are more malleable, and so to be open to that, though. I think a lot about these things, I spent a lot of my time thinking about these things, not everyone has that privilege to spend a lot of time looking at the data, really thinking hard about, “is this data valid or accurate and quality data?” “What's the best research out there on a certain topic?” that's kind of my job along certain dimensions. When I see things on Facebook or Twitter that are getting so much attention yet are demonstrably untrue that to me is something we are going to have to work to overcome, to educate the population, to say–I mean Facebook tried there's been attempts to say this is really not true, or this is questionable. But how people respond to that data? That information? We don't have a situation of perfect information and even what people do with the same piece of information in terms of their beliefs. The last year that's become dramatically different than in a lot of cases. It was really dispiriting and disheartening to see how some people have taken certain data that and twisted into the vaccine is going to kill babies, or people got COVID from the vaccine, or the things you can see now. I think the way people will take that as truth to me is incredibly challenging for health care, for our population, and for our government. To develop solutions in situations like this, where there are massive externalities. 
Externalities are when our behavior affects other people. So, the more vaccinated we get the easier it is to avoid the virus and to not have another outbreak. And yet, even with the last [700,000] people dead [others] will even dispute that. That it is not even an accepted statistic. Like, “No it's a lot less than that” and I believe it's actually probably a bit more than that–but again–that's a belief I have based on my experience, based on my training, and based on what I read. I think how people respond should [be], “Man that's a lot of people! That's a tremendous amount of mortality that's come from this virus. I want to do everything I can to stop that for everyone, not just me, not just my wife, my child; I don't want more people to die of COVID, what can I do to make that happen? I'll wear a mask, will get vaccinated, I won't go out to eat without a mask on the first day it is available.” Okay, not a big sacrifice by me, frankly, and you have some people that viewed it as such an encroachment on their life that they will not even make that sacrifice. 
 
I've ended on a really not a great note. It had some hopeful pieces I think in there, but... 
 
Rick Sindt

Yeah, um, maybe a challenge to close us out then would be to tell us in a few sentences what are your hopes. 
 
Tim Classen

My hope is we all get universal coverage. Having everyone have health insurance in the system, including the undocumented population in this country, everyone living here needs to have health insurance of some sort. That's a worthy goal that I would vouch for and push as much as I can. 
I think that will improve people's health. [How much is] still an open question, sometimes it is not insurance that improves people's health but, in general, I think that has been shown to be the case. How much it will improve people's health; it's not a panacea that people get better with health insurance but, in general, having coverage is essential. 
 
Increase in telehealth for the rural population, for the underserved populations and–let's go back to where I began with discussions around mental health. Access to mental health care is improving. You know Naomi Osaka is the latest, very public, example. I think Gen Z is much more adept, willing, and frank about their mental health challenges than even the Millennials and us Gen Xers. We were known as the Depression Generation, we had Kurt Cobain. This was our generation, but I think it is encouraging to see someone like Naomi Osaka, a very public figure, come out say, “I'm not going to play tennis because my mental health isn't where I want it to be and i'm suffering.” 
 
I don't like that she's suffering. I don't like that she's not playing tennis. But I am incredibly happy and grateful that she wanted to talk about it publicly. I talked about my own mental health care with my students quite often, I think it is essential to talk and to not suffer in silence. That, to me, out of all this is probably the most hopeful thing that's come–Oprah Winfrey now has a new series on Netflix about mental health. The public discourse around mental health care just during my lifetime, and just in the last 10 years, is very encouraging. People need to get treatment. People need to not suffer in silence. This extends to a variety of situations in people's lives, identity. Obviously, identity and the willingness and ability to talk frankly about our identities has rapidly changed and in just three years has changed tremendously and so that goes along with mental health and access to mental health care. 
 
Telehealth is improving access to mental health care but we still need more providers. We're under subscribing to the psychologists and psychiatrists; we need more people to go into that field, we need to compensate them fairly, we need Medicaid to pay those providers better for those services so everyone has access. There are still a lot of people who don't even take insurance it is $300 for 45 minutes of care. Not many people with mental health problems can afford that, and so we need to get people who are in the lower half of the income distribution better care and better access. But the discussions around it, the new generation’s willingness and ability to talk about it frankly, to be public about it, to me that's been encouraging, so I will end on that happier note. 
 
Rick Sindt

Great, thank you so much for joining us today. 
 
Tim Classen

Sure, glad to do it. Glad to talk with you, Rick. Thanks so much for having me. 

*This transcript has been edited for clarity.