The Exchanges

Q for moms and babies, and that's something you're obviously very passionate about, but zooming, zooming out for a second, I want to get your thoughts in general about healthcare. Healthcare costs are going up every year. Uh, productivity in this space is declining. It's one of the only places where productivity goes, tends to go down over time, which is crazy. Outcomes seem to be relatively flat. What's going on?

A Yeah, we have a crummy healthcare system in the US, right? We spend way too much money on it, and we don't get good outcomes for our money, and that spend is crowding out, spending on, I mean, as Secretary of Health, I knew it was a zero-sum game, right? The US can print money and borrow from China. Well, you can't when you run a state. You have a zero-sum game, so when one thing goes up, another goes down, so when healthcare spending goes up, education spending goes down, and arguably, health Is more related to education than healthcare. Um, and you don't actually don't have to argue very much to make that point. So, you know, it was frustrating to me. And, uh, but the problem is the political machine, uh, is very interested in keeping the status quo, right? So you have all of these companies making a ton of money.

AI assessment note: “the problem is the political machine, uh, is very interested in keeping the status quo”

Q You actually led an effort as Secretary of Health in Louisiana to improve birth outcomes. Like, what were the key things to improve the outcomes? It was just how they're sleeping, is that kind of stuff?

A That's important, but I mean, certainly as Secretary, I focused on hospitals because that was in my purview. Um, you know, are we treating hemorrhage when it's happening? Are we treating hypertension when it's happening? Um, are we safely delivering babies at the right time? Are we doing C-sections only when needed? So that was kind of before, and now, and now really focused around, and then also birth spacing. Are we, are we able to, and Louisiana made huge strides in availability of birth control. You know, our planned pregnancy is happening at a greater rate. Now we're focused on, okay, You've gotten, we've seen this at home. You've got a mom who went home with high blood pressure of, so half of maternal mortality happens after moms go home. So, and a lot of it's cardiovascular. So she had an enlarged heart, right? She had high blood pressure, but no one's checking. We know that moms will, even though, and I gave you the data on kids, 59% don't get all their well visits. Even fewer moms get their care. They're focusing on their kids. First. So if they're not getting their hypertension treated, they can have a stroke. They can have chronic morbidity. You know, if they have gestational diabetes, 50% of them will have diabetes. That doesn't get treated. You know, then you get, you know, diabetic foot ulcers, all, you know, put this down the line. So it's about, and then with ki…

AI assessment note: “certainly as Secretary, I focused on hospitals because that was in my purview.”

Q And, and tell us about some of your big healthcare initiatives. You've done some big things with drug pricing, right? Innovative work around like Sovaldi. That was, that was hepatitis C drug.

A That's right, Joe. Yeah. So I've, I've tended to like to find problems have come to me and instead of saying, Hey, look, this is insurmountable. I have tended to and enjoy the times in my career. I've had the most fun or saying, okay, look, this is an awful problem. How do I solve this problem? And when you and I first met, we talked about, well, here are 20 problems, right? That ought to be solved. And so that was my approach as I did my government work or academia is first, I looked at the problem of reproductive health access. How do we get access to plan B? Emergency contraception. Did work on that. Sued Walmart. Won a national lawsuit.

AI assessment note: “first, I looked at the problem of reproductive health access. How do we get access”

Q What do you have to sue them for?

A Yep. Because I had a patient who went to the pharmacy to get her prescription filled for a prescription I wrote her for a plan B. A mom that had a bunch of kids didn't want another one. Wanted protection. Couldn't get it. And so under the state of Massachusetts required that all commonly needed prescriptions be available in pharmacies. So we won it. And then Walmart changed its national policy. So That was when I was a resident at the Brigham in Boston. And so I got a taste for a while, even as a young person in my twenties, I can, uh, be an advocate and make change. And so, uh, in state government really led the work to address quality outcomes for moms and kids, starting with dashboarding out what those outcomes were, then focusing on really key areas we could improve. Uh, and then as secretary of health looked at a bunch of things, how do we run disciplines? Disability services better. We had a 25 year long waitlist that was average weight of 13 years for kids. 25 years.

AI assessment note: “Because I had a patient who went to the pharmacy to get her prescription”

Q you're, and you're taking, seeing patients that weren't getting care otherwise, weren't having primary care for otherwise. Stepping back because you've done so much in policy in this world, like, like what should policymakers be doing to make this easier? It's that, so that more Rebecca Gies can come and start companies to do things like this, like, or what else should we be doing to, to fix the system?

A Well, we need more Joe Lonsdale's. It's a real deficit to have not started a company before. I hadn't. I, my background was all in government, which is what you need to start a Medicaid company, right? You have to understand it to, to have worked in it gives you the best opportunity to understand it. But generally who gets funded are people that come from that world, uh, that is the, um, you know, either the financial side or they've already done a startup, which means that you don't get those outside ideas. So you're willing to bet on people And I've seen this in so many of your companies who are coming in with a different idea. They want to take a crack at it from a totally different perspective. So we need more of that. We need more venture funds that are willing to take a bet on big intractable problems and support founders who are expert, but may not have, and then support as you did with ABC, then surround them with people who know how to build that dynamic.

AI assessment note: “We need more venture funds that are willing to take a bet on big intractable”

Q And it's notoriously difficult to innovate within Medicaid. You're starting in Louisiana and Medicaid, like, like, obviously you're based in Louisiana, so you're starting there, but, but why, why Medicaid and how are you managing to innovate there?

A Yeah, Medicaid's really hard. Actually, when I ran Medicaid, my staff got, I didn't condone this, but they all got t-shirts made one day that said Medicaid is hard and wore them, and I was like, that's totally the wrong message, but it is really hard, and, um, because there's the idiosyncrasy of state policy, there is a government framework that's federal, but there's so much variation, and then there's high burnout and high turnover, so there are very few people that understand it like I do, right? I've been a secretary of health, I've been a medical director, I've Run and been responsible for the Medicaid program. My co-founder has worked for both Geisinger and Kaiser. She's worked for Landmark. She's got deep experience in FQHC. So she, it's kind of.

AI assessment note: “there are very few people that understand it like I do”