Why Healthcare Costs Are So Hard to Bring Down | Robert Pearl

Healthcare costs are going up significantly every year and they're outpacing the inflation rate. Right now they have reached record $28,000 per family in the U.S. and next year they are projected to go up more. Today we sit down with Dr. Robert Pearl who's an insider in this industry. He's been the CEO of Kaiser Permanente. He tells us today what's really behind He also teaches in Stanford. the numbers in the healthcare cost and if there is a way to improve the care quality and lower the cost. I'm Siamak. Welcome to Market Insider. Robert, it's great to have you on. Welcome. Thank you very much. It's a privilege and a pleasure to be with you today. We want to talk to you about health care costs, and you're an expert, you're an insider in this space. Right now, we are at record. It's $28,000 for average family in America to get health care benefits. Some of it we are paying out of pocket, and some of it the companies are paying, so it's kind of confusing for people. Most people may not see this $28,000. But this number keeps going up every year. And sometimes it's 7%, sometimes it's 10%, sometimes it's 6%. Tell us what's happening with the health care costs right now. Well, health care costs are continuing to go up with the $28,000 you're talking about. Remember, this is the cost of private insurance, by which I mean these are younger people. These aren't the sickest people in our nation because Medicare is a separate funding with a different price point. But in terms of that, about three quarters is paid by the employer, one quarter by the employee, the worker. And remember, it's being paid with post-tax dollars. When you get your coverage through your employer, there's no tax on it. When you pay your part out-of-pocket, your contribution to the premium and your out-of-pocket expenses, that's post-tax. We're talking about having to earn something like $10,000 to $12,000, particularly if you work in a small business where the average cost to an individual and obviously to the family is over $9,000. Imagine if you earn $50,000 and now you're They're going to pay post-tax 9,000 health care. That's incredibly difficult. And why half of the people in the United States today say they can't afford their health care. And where does this money go? Are there components that this money goes to? If you look overall, we spend $5.7 trillion a year across the United States on health care. Compare that to the GDP. This is the total gross domestic product. All the goods and services that people consume. All right. This is going to be 20% of the U.S. GDP, but it's higher than the total GDPs of every nation in this world, except China and the United States. So it's a tremendous amount of dollars. And of that, the biggest piece goes to hospitals. That's about 30 to 35%. Five percent? Somewhere around 20% to 25% go to physicians. Another maybe 15% or so go to the drug companies. And the insurers, according to the Affordable Care Act, are allowed to not use on direct health care up to 15% of the total premium. So that's the basic breakdown of the cost that's there. And according to the Commonwealth Fund, not only do we spend more per American on health care than any other nation in the world, almost double, almost every company except for Switzerland and Germany, every country besides Switzerland and Germany, but the outcomes we get, they lag. We are at the bottom on longevity, how long people live. We have the worst maternal mortality. In fact, we're higher than the second and third worst countries. We have the highest mortality for children. We're not getting the value that we deserve for the dollars that we're spending. So we want to dive into all that to find out why, but there's another element here that the pace of growth of health care costs is higher than inflation. Why is that? Well, first, let's talk some numbers. For the past three years, the cost of medicine, medical care in the United States has gone up 7% a year. Next year, Even after benefits are going to be reduced, it's still going to be 9%. We're talking about more than double the overall cost of inflation. Now, why is a very debated question. We certainly have high prices, but we pay on drugs as an example. We pay two to three times more for drugs. ...than other nations in the world. We're talking about peer nations. And why do we do that? Because Congress said that the federal government can't negotiate prices. That the midterms are over. That could change. But that's where we stand right now on drugs. We know that hospitals have consolidated to gain market control. You can't sell an insurance product unless there's a hospital within 15 miles or 30 minutes. of where the individual who enrolls lives and so they can now raise the prices and we see physicians now 70 percent working for either hospital systems or private equity. So we see a lot of push that's there and I want to also add that much of the staff is unionized with rates and wages that are significantly higher than other segments of other industries. From what you're saying, it seems like the competition is gone. Like there's not a lot of competition among these different components of the healthcare. Absolutely. I think if you look at each of the segments of the marketplace, what you see really over the past two decades is that rather than trying to compete at higher quality, Or rather than trying to find the operational efficiencies to lower costs, the approach that they have used is to be able to gain monopoly-type control over an industry or a geography. Let's look at each of the pieces of that. The drug companies have patents for 12 or 13 years. No one can compete with them because of those patents. What you see is that the average new drug in the United States is over $300,000 a year. You look at the GLP-1 medications, the weight loss drugs. According to a study from Yale University, it costs about $5 to make one. If you add maybe $15 more for distribution, some profit, et cetera, it should cost $20. They retail for over $1,000. Because the patent protection means that competitors have difficulty or can't compete with them. Hospitals, get another Yale study, half of the hospitals in the United States dominate a single marketplace. As I said, you can't sell insurance without having the hospitals as part of that program. And so now we're looking at, again, costs that are significantly higher than they otherwise might need to be. And as clinicians join hospitals or private equity, we've seen about a 15% increase in the cost of that care, the price of that care. So each piece has figured out how they can get their arms around that market and raise the prices as their strategy to do relatively well in a difficult economic. It's a condition for much of the nation. Now, some people say that we have a lot of innovation because of this, especially in the drug space. When you have the patents, you can put the money into the research and development, and that's how we end up making all the drugs, and then the rest of the world copies us. What are your thoughts on that? The people who say that are the ones who benefit from the market control. There's very little data to support it. More money is spent by the average drug company on marketing and sales than is spent on R&D. Nearly all of the advances are done by small companies that then simply get acquired by the larger companies who are the ones who actually sell the drugs. It's often called most favored nation status, the same prices as Europe. The estimates are that at most, we would see one fewer drugs brought to the marketplace each year. I think they're right that other countries are not carrying their weight, but the United States is carrying excessive weight. And much of the research, by the way, that's done by drug companies comes out of the NIH. It comes out of government-funded projects. So I would say that, No, that's a threat, but it's not one that has a lot of validity. Behind it, as I mentioned earlier, we don't have great healthcare outcomes. It's not very innovative. I'd say if anything, the system is ultra stable. You know, I teach, as I said, at the Stanford Graduate School of Business, and I tell my class that the most common way that clinicians exchange vital patient information today is fax machine. And a hand always goes up and says to me, what is a fax machine? They've never seen it. It's an 1834 invention. No, I think it's the opposite. We have a very un-innovative, non-innovative healthcare system today. We have generative AI technology, technology that could. Help monitor patients every day in their home. Could empower them to be able to get medical expertise that could help us to control chronic disease far better than today. And none of that is happening. According to the CDC, if we could effectively control chronic disease, not perfectly, just as well as the best places in the nation are able to accomplish. We would have, catch this, 30 to 50% fewer heart attacks, strokes, kidney failures, marked reduction in cancer, and over a trillion dollars in savings. And yet, we don't do any of that. So far today, the application of generative AI is almost entirely around administrative functions and battles between providers and insurers over billing and claims. Why do you think there is not enough innovation going into this? It comes down to money. It comes down to how many of these are for-profit companies, what's going to happen to their underlying stocks and profitability and price-to-earnings ratio, all the things you talk about often on the show, and we're in a situation where it's just a better business, an easier choice to be able to address healthcare by gaining market control and raising prices than it is. By being able to put these innovations that would keep people healthier. I mean, imagine if we had 30, 50% fewer heart attacks, strokes, kidney failures, and a significant reduction in cancers. What happened to the hospitals in this nation? All of a sudden, the patients wouldn't be there. That's not something they can embrace and push really hard. What about all the specialists? Specialists make almost double what primary care makes. They're not going to be very happy if they have fewer patients to do procedures on. And the drug companies, you know, all these new expensive drugs, the ones that I mentioned cost $300,000 a year. These are ones for conditions that we could, in many cases, prevent, or at least prevent the worst of the complications from occurring. That's the situation that we have today, so there's no impetus to do it. The government has not been willing to wade into the water. I think it should, but it hasn't been so far. And the truth is that patients are helpless. They have very little power in the healthcare system today, in spite of the fact that I believe that they should be central to the care delivery processes. And the best opportunities that we have are to empower patients. But that, of course, would have a negative impact on the rest of the world. You know, the cost of health care. It's negative for the patient, but it is the source of income and revenue for so many of the incumbents in the healthcare sphere. So from what you're saying, this has become a business that wants to make more money. And the more the costs go up, the more income for these companies that are in this space. But then at the expense of it comes that we could have prevented some of... These diseases and some of these issues, but it would have cut the revenues of these companies and nobody wants that, right? Absolutely. That's the situation today. It is a big business that's sitting there. I don't want anyone to think that I'm saying these people want individuals to get sick. It's just that they don't have any incentives. You know what Charlie Munger said? Tell me your incentives. I'm going to tell you the care you're going to get. Medicine Today is paid on a pay-for- volume system. We call it fee-for-service. The more you do, the more you get paid. If it doesn't do any good at all, it doesn't matter. Physicians and hospitals still make as much money as they would before. The shift that has to happen, I believe, is to move. From fee-for-service to a pay-for-value, of which I think capitation, we're talking about a single payment made to the providers of care, the doctors and the hospitals, not to the insurance companies, to provide the totality of care to a population of patients. And as soon as we made that move, now the incentives align. And I'm very optimistic that all of a sudden, we'd find a lot of efficiencies. We'd be preventing a lot of heart attacks and strokes and kidney failures and cancer because that's now how they would make the maximum amount of money. So it's not the fact that it's a for-profit type industry. It's that the incentives in the industry today are just to do more. And the incentives that we need are to do better. Now you have been in this space yourself. Besides doing research on the cost, you have been an insider. What was the moment or what was the time you figured out that something is broken in the system? Can you tell us about that? I did my medical school at Yale, and then I went to Stanford for a residency. And when I was in my last year of residency, I was specializing, I'm a plastic surgeon, I specialize in kids with cleft lip and cleft palate. I was planning actually to head to South America and do a lot of the type of mission work that I had done during my residency time periods. And the plastic surgeon in Kaiser Permanente in Santa Clara, the facility there, died in a tragic plane crash. And they called me up and they said, You know, we don't have anyone to do this work. Would you come help us out for six months until we can hire someone? And I said, of course, you know, happy to do so. And when I got there, I would say that was my first realization because I saw all these physicians working together as one, not competing with each other. You know, I saw that the patient didn't I have to pay large bills, often it was $5 out of pocket to see a physician, or maybe it would be $25 to support the inpatient admission, and I would say it was at that point that I started to see many of the problems. And then 15 years later when I became the CEO in Kaiser Permanente, obviously by then I had the opportunity to make the changes. And we put changes in place to control chronic disease is a great example of that. We put in place an electronic health care record system, which when we first put in was revolutionary. It was right at the cutting edge. And we were able to lower the chances of our patients dying from a heart attack or a stroke 30% below the community around us. The National Committee for Quality Assurance recognized these outcomes. Colon cancer, we're able to lower the death rate there by 30%. This to me was a recognition of what was possible when two factors, what I'll call three factors sit in place. The first factor is this integration. Primary care workers, specialty care, everyone collaborating and coordinating and communicating. The second piece was the payment methodology. That 95% of the income came out of a capitated payment, a single payment. And therefore, prevention became a major, major driver. Similarly, control of chronic disease became a major driver. And the third is a leadership structure. You know, every hospital has an administrator and every insurance company has a CEO and every physician group has some type of leader sitting in place, but there's no one who can make these changes. That's why I believe that right now, particularly after these midterms, that Congress is going to have to step forward and be able to facilitate some of these improvements, because I don't think there's anyone, even if the industry wanted to make the changes. There's no one in a position to actually make it happen. If you're an independent thinker that's looking for factual information, and when you read a story, you want to know the multiple sides that exist in the story, you want to check out the newspaper Epoch Times, theepochtimes.com. We're actually part of the Epoch Times newspaper. And the goal of the paper is to bring clarity for independent thinkers. Make sure to check them out and if you like subscribe to them. Now let's go back to the rest of this interview. So you don't think the changes will come from the industry but another question for you is when you made these changes did Kaiser become more successful financially or the financial incentive was different than actually the quality that you guys delivered? When I became the CEO, I was not looking for that job. The CEO ahead of me was in the process of being fired. We were down to two days of cash. And according to the law, we have to have three days of cash to stay viable as a provider of insurance company. The Kaiser part, Permanente is the delivery system, Kaiser is the insurance system. But the Kaiser side was down to two days of cash. We had to borrow a day of cash simply to continue. At that time, we had about a 34% market share. And when I left, we had gone up to a 46% market share. We had 60 days of cash. Yeah, it completely turned things around because now we had a successful way to keep patients healthier. The average patient in the community often waits a week or two or three and maybe a month for a consult. We were seeing 70% of people for routine problems. We're not talking about the emergencies. They all got seen immediately. Routine problems, 70% of people in a day or two at most. That's a remarkable change. A patient's satisfaction, was incredibly high. The quality outcomes, according to the National Committee for Quality Assurance, was number one out of a thousand programs in the country. And not only that, but the physician satisfaction, which as many people know, is a lot of burnout sitting today. It was 20% higher in the community around us. People want to be on winning teams. I don't care if you're talking about sports or symphony orchestras or wherever it's going to be. They want to be doing a great job, getting great outcomes, being successful, and that's my belief. We have that opportunity, but the opportunity has to start with a change in the underlying system and its methodology of payment, a system that's going to reward. Value, reward, keeping people healthy. And when you do that, all of a sudden the spirit improves and people have a sense of fulfillment that they may not have had before. Now, you mentioned changes in policy. From what I'm gathering is that it's possible for the insurance providers to do something. And I want to ask you about the policies, ideas that you have, but what's the limitation from the insurance providers? It seems like you guys did that and it did work. Can other insurance providers pressure the healthcare system to ask them to look for more prevention to cut the cost and improve the service? Well, the big challenge the insurance company has is they don't have a direct relationship with the physicians providing. It's just contractual relationship and it's on this paid fee-for-service basis. Here we had myself, who was the head of the delivery system, and the CEO of the insurance side, and we'd sit down, we'd negotiate a contract. We'd figure out how we could provide the best care, keep the people the healthiest, because what was best for them was also going to be best for us in our capitated system. That's the challenge right now with American insurance today. They don't have that. Everyone's on a transactional, a fee-for-service basis, and that's why you see the battles. That's why you see prioritization. The American insurers, outside of integrated organizations like Kaiser Permanente, the The other insurers... have no ability to control the care that's delivered. They may be contracting with 50 doctors, 100 doctors in the community, all of whom have separate offices. They're unconnected with each other. They might not even be using the same computer system. Maybe they can't exchange the patient's information. All the opportunities to improve efficiencies are simply problematic. You know, I'll give you an example. If you're admitted to a hospital on Friday with the same problem as Monday night, Friday night versus Monday night, it will take you a full day longer to get better, a full day longer to be discharged from the hospital. It's not better care, it's worse care. It's higher cost, but there's no ability that the insurer has to create that efficiency today. So you have to pay more because you stay there, you stay there one more day, you got But less care. And, but you have to pay more because you were there longer. Is that how it works? And your chance of a complication went up dramatically because hospital acquired infections are one of the leading causes of complications, one of the leading causes of patient deaths. You may have what's called delirium. I don't know if you've ever been in a hospital, but it's not a nice place to sleep. And so at night you don't get any sleep. And by the time you add four nights instead of three nights, your chance of delirium goes up. The food is terrible in most hospitals. And so your nutrition goes down, everything is bad, but no one has that ability to make the change and the insurers can't. So what do the insurers do? They put up barriers, prior authorization. You have a problem, you need to have care, but it's expensive. I'm going to make your doctor jump through a lot of hoops and hope that maybe the doctor will simply say to you, no, you don't really need it, even though you do. I'm going to basically be trying to drive down by pennies and dollars what I pay to the doctors and the hospitals. And what are they going to do? They're going to raise their volume. And you can say, OK, what do you mean raise their volume? Well, a lot of medicine can be handled in more than one way. And sometimes. A less efficient way is more remunerative, and often that's what we see. We'll admit you to the hospital. We could have taken care of it at home. I could have seen you in the office. I'll send you to the ER. All those types of changes, and I want to emphasize for viewers and for listeners, every one of these compromise quality, compromise clinical outcome, none of them improve performance or clinical results. In terms of policy recommendations, do you have any thoughts? Can the federal government fix that? And also, how much room is there for improving efficiency and lowering the cost? There's a massive amount. I've already said that we could save a trillion dollars. That's 20% of the health care budget. If we simply did one thing well, which is to control chronic disease, and we could do that, the combination of GLP-1 medications for obesity, along with generative AI tools to be able to manage chronic disease, these are easily able to accomplish it. And the government could do it. It could address GLP-1s by forcing the providers to not charge the rates. You may remember way back when the first GLP-1 drugs were released. What we saw is there were not enough supply. And so what's called compounding pharmacies would make the drugs and sell them at under $100 each. So we could provide it. And as I said, if it costs $20 to create the drug and market and sell it, and you sell it for $100, you have a 500% profit. That's the opportunity that sits there. It doesn't have to be $500, $600, $700. We're talking about on a monthly basis. And number two, I think in terms of the generative AI tools, we could build them. We can build tools. If you have hypertension, we could measure your blood pressure in your home three times a day for an entire month. And at the end of the month, we can say whether your medication is working or not. And if it's not working, we could have the clinician using a quick telemedicine visit. Be able to improve it, raise the dose, find another medication. But instead, the doctor told you that he or she will see in three to four months. And so there's always a delay. We don't effectively do it. We control hypertension. Remember, 40% of strokes come from hypertension. We control it less than half of the time. And diabetes, we do even worse. That's the leading cause of kidney failure, major contributor to heart disease, 80% of lower limb amputations. We can go on and on with the opportunities that's there. Right now, there's an expensive regulatory process to bring many of the generative AI tools into health care. The NIH could do that, coordinating with some of the large language model companies like OpenAI and Google and Anthropic. And they could bring in clinicians and create these tools to empower patients in their homes and make them free. You know, the nice part about creating applications is once they're built, there's no additional cost, very little additional cost. And so they can make that as a service to improve the health of the nation. I would love to see the new Congress do that. You know, the Democrats have talked about wanting to be the party that moves forward. the health of the country. But if you're on the other side of the equation, you say, no, we don't want the government weighing in on this in any way, shape, or form. What we want is more competition. Listeners and viewers may know that through the Affordable Care Act, if you have individual coverage, you go to an exchange. And the exchange is where you purchase the insurance. But you have a choice. You can choose amongst many different companies. You can choose different levels of coverage based upon how much money you're willing to pay. And there's a program in place where rather than the employer, we just said you start the conversation with $28,000 statistic. Rather than the employer paying $28,000. They could give it to you, the worker. And with that $28,000, you could pick the best program for you and your family. And by the way, if you could find one for $22,000, now you have $6,000 that you can save up into either a health savings account or maybe even take home, pay taxes on, but be able to keep the remainder. It's a lot more opportunity. Now, just think what would happen. As I said, we have very little competition today. But as soon as it moved on to an exchange, we could have a variety of new startups be able to offer alternative programs. We could have clinicians working in their local area to create programs that are going to be cost effective. And now all of a sudden, there's downward pressure. This is what real competition does. We can break up the monopolies of health care. If the government were willing to make that possible using the program that currently exists to allow employers to accomplish that, that's a competitive solution. We could probably come up with a variety of other ones. The one thing I will say is that simply tweaking insurance, simply trying to make small changes, that's not going to work. And I want to add one more piece because a lot of people are now talking, particularly some of the newly elected individuals, Medicare for all. What people need to realize is why Medicare is affordable today is that Congress has given the federal government the opportunity to impose prices, and they impose prices that are about 90% of the cost of providing the care. Now, if everyone said, okay, well, I guess if that's all we have, we can find the efficiencies, that would be great, but that's not what's happening. What's actually happening is that the private companies are paying two to three times, 200 300% of that cost to offset. The insufficiency coming out of the Medicare program. If all of a sudden everyone's in Medicare and all the hospitals are getting paid at 90%, we're going to see a third of them close or some pretty massive number because already we have something like 25 or 30% that are on the verge of bankruptcy. So we have to be very careful what we do. I believe we either have to lower costs by keeping people healthy. Or we have to increase competition. In terms of competition and pricing, a lot of us, a lot of people have no idea what they are paying for when they go get a procedure. And they have no idea how that compares to one hospital versus another hospital. Is it possible for hospitals to publish these rates? And there's been some pushback from hospitals saying it's very difficult to do that. What are your thoughts on that? Well, there's actually a law that says they're supposed to do it, but you're absolutely right. I would, more than pushback, they're just simply finding ways to get around the law. And how do you do that? You make the whole system so complicated. He provides so much detailed information that no one can understand. It's like reading an insurance policy that's 11 pages long in small print. You have no idea quite what all that means and what it says. And that's where we are today. So that's the first thing that I would say. The second is, if you're having chest pain, are you going to start thumbing through the prices for heart attack treatment based upon your community, or just get to the nearest hospital you possibly can? So much of the health care that we provide today. is on an urgent and emergent basis. And so I am doubtful that that price will work. But I'm also a proponent that transparency is important. And the reason it's important is so that Congress and policy experts have the data that they need to figure out what's going on. I'll give you an example. In the state of California, the state said, we want to understand what the cost of a total joint is. When they started checking around and made all the hospitals report, believe it or not, it varied from 25,000 to 125,000. When they looked at the outcomes, they were identical. The $125,000 hospitals didn't get any better outcomes than the ones that were $25,000. And interestingly enough, when the state said, we're only going to pay $25,000, guess what happened to the prices? They all came down to $25,000. It's not that it couldn't get done. It's that it's just not what people. But the hospital industry wants to see it happen today. For some of our audience that are looking into potentially investing in health care, is there any sectors that you see that there's opportunities? And are there any sectors that you kind of want to stay away from? Investment is challenging in every industry. It's like asking, well, what about in the AI world? It could be the best investment in the world. It could be the best, the worst. Of course, you know. Should you invest in SpaceX? Should you invest in Anthropic? These are the challenges. And I would hate to tell someone any specific information because they have to weigh the various risks. I'll give you some examples. So if you look at the pharmaceutical world, the challenge right now is three. First of all, what we see is what's called a patent cliff. Many of the most profitable medications that are being sold today are going to be coming to the end of their patents sometime over the next five years. Well, they're going to have to look for ways to pivot. Do you think they'll be able to or not? That's what will drive the determination of whether your investments should be there or not. We've said that some of the treatments are many times more expensive in the United States than in Europe. You've got to weigh in. What will the Democratic Congress now do? President Trump has talked about. Most favored nation status, if Congress passed legislation around it, that would be a massive risk. If they don't, it's still a big opportunity. So I would say that the industry, it's been one of the most profitable segments of the entire... I am. Dow Jones and S&P 500 over the past decade, for-profit hospitals have done well, surgery centers have done well, drug companies have done well, and insurance companies have done well as well. So I think it's a very attractive industry, but it's also one that has a lot of new risks and threats that people need to understand and research. And maybe even talk to some experts about specific companies before deciding to invest in them. And do you see a change coming from outside of the current setup? Is there some alternative medicine type programs out there? And do you see that taking off and kind of becoming part of this healthcare system? I write for Forbes, and actually my next article is going to be about the ultra-stable nature of healthcare. And people want information, they go to my website, Robert Pearl MD, to find it. But the opportunities to enter the marketplace are very challenging. I mean, think about it. A drug company, you're talking many, many billions of dollars you need to create a new set of laboratories to, before you're going to get a return, which by the way is often eight or 10 years in the future. You're talking about hospitals. It's now over $2 million a bed. When a hundred bed hospital, you need $200 million just to start. You want to create a medical group and bring in doctors from all different specialties. So what's called barriers to entry are very great in medicine. And I think that that's why, you know, Clay Christensen was a friend of mine before he died and brilliant, brilliant researcher. He talked about disruptive innovation. It's why disruptive innovation hasn't come in medicine. It's not that people don't have the ideas. It's that making that first investment, all the disruptors are able to get into the marketplace For a relatively small amount of dollars. That's why they can be entrepreneurs. You just can't do that easily in medicine. Yes, you can create products that you can sell that are going to raise revenue, that increase profits. They exist. And there's certainly a bunch of unicorns that have come out of that. But I think the disruptive type changes that are there that you're describing would be much more challenging. But that's why I gave you the examples that I did. I mean, the government lowering that barrier by building a lot of the technological tools that would be needed, or that competitive space. You could enter into a marketplace in a very small geography at a price that's now possible. So I think that that's the biggest challenge that's there is why the change hasn't happened. So I don't think we're going to see disruption in the typical way that a small entrepreneurial company comes in, gets a place, and then expands from it. I think it's going to have to either come from an insurer deciding that the FIFA service world doesn't have legs and they're going to move into a capitated world, or I'm hoping the self-funded businesses we're talking about. It's 160 private employers that pay for coverage. Half of those, about 80 million individuals, are covered by self-funded businesses. And I would hope that they would be willing to do that or some type of self-funded business government partnership. The government's going to create the tools, the self-funded businesses are going to implement it. I can see a lot of ways it's coming. The one thing I know is that when something can't continue, it won't. We have a deficit nationally of $40 trillion. It's still going up. We're going to pay $2 trillion in interest alone next year. We're seeing the bond market go up to rates that were unimaginable even a couple of years ago. Change has to happen. The challenge is going to be who's going to lead it. And who's going to take the risk and who will take, I'll call it the heat of making the shift happens. Everyone agrees where it needs to go. It needs to move to pay for value, but making that happen, it's like standing on one edge of the Grand Canyon and looking to the other side, it doesn't look very far away until you realize you're going to go all the way down, all the way across the river, and then all the way back up. It's the transition that will be most difficult. Once we get there, we're never going to go back. If we had to create the system of today, we never would do so. The American medical system will be changed. But as you point out, the question is, by whom? Because if it's not changed, rationing will be the only opportunity that exists. And we will see the health of our nation decline and a vicious cycle created. That's something as a physician and as an American, I hope, never will happen. Dr. Robert Pearl, it was great to have you on Marketing Insider. Please come back and update us on what you're seeing out there. It was a pleasure to have you on. Happy to do that. I appreciate your helping to educate people about all the opportunities in the healthcare world. Tell us what you think about this conversation with Robert. Do you know how much you're spending on your healthcare costs? A lot of times the employers are paying for them. And do you have any thoughts about the healthcare system? Make sure to tell us in the comments below. I'm Siyamak, this is Market Insider. We'll see you next time.