{"id":886660,"date":"2026-10-18T13:48:43","date_gmt":"2026-10-18T13:48:43","guid":{"rendered":"https:\/\/www.newsbeep.com\/us\/886660\/"},"modified":"2026-10-18T13:48:43","modified_gmt":"2026-10-18T13:48:43","slug":"did-neoliberalism-infect-american-health-care-a-debate","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/us\/886660\/","title":{"rendered":"Did neoliberalism infect American health care? A debate"},"content":{"rendered":"

Welcome to Friendly Argument, a new STAT First Opinion series in which two experts who disagree but respect each other\u2019s point of view engage in a debate about medicine and health policy. In this installment, John E. McDonough<\/a>, author of the new book \u201cAmerica\u2019s Wrong Turn: U.S. Healthcare in the Neoliberal Era<\/a>,\u201d discusses the roots of U.S. health care dysfunction with Stuart Butler<\/a>, a scholar in residence in economic studies at the Brookings Institution. Their discussion was held on Zoom.<\/p>\n

Below is a lightly edited, AI-generated transcript.<\/p>\n

Torie Bosch: You two have been disagreeing on health care policy for about two decades now, is that right?<\/p>\n

Stuart Butler: Not always disagreeing. I think perhaps disagreeing more on methods and what I\u2019ll call engineering issues than on principles of where we want to end up. So we\u2019ll see how it comes out.<\/p>\n

Bosch: Even better.<\/p>\n

John McDonough: I got to know Stuart from a distance when I was in the Massachusetts legislature and he was a prominent national voice on health policy as one of the early employees at the Heritage Foundation in Washington, D.C. I heard about him, saw his work on many, many levels, not just on health policy. And when I went to D.C. in 2008 to work on what became the Affordable Care Act, working inside the U.S. Senate, I quickly reached out to Stuart, and we started conversations. And he brought me into the inner sanctum of the Heritage Foundation and we started this exchange.<\/p>\n

Part of it was because I was involved in Massachusetts since the 1980s. And we started a big effort in 2003 to create some kind of universal coverage vehicle. It was done during the term of Gov. Mitt Romney. And Mitt Romney either got contacted or reached out to the Heritage Foundation, and they acted as his principal national advisers and were quite important in his agreeing to put into the law an individual mandate for people to buy health insurance. And so even though I was from the Democratic side and he was from the Republican side, there had been this cross relationship going back several years around Massachusetts health reform where we both agreed on an individual mandate. And so, you know, what else might there be that could flow from that?<\/p>\n

Butler: And I might add that it wasn\u2019t just an agreement on a mandate, it was an agreement that everybody should be able to get access to affordable health care. And we argue to some extent about the methodology of that, but not in Massachusetts, not greatly. I would also just add something to what John said. Yes, he came to work in Washington and came to work for Ted Kennedy. And just as I\u2019ve always thought there were two Ted Kennedys, I think there are two John McDonoughs. And they very much reflect his experience with Ted Kennedy. There was the sort of chest-thumping John McDonough, you know, because Ted Kennedy would denounce people and say they really were totally opposed to doing what was good for the world. And there was the other Ted Kennedy and the other John McDonough, which meeting quietly at the Heritage Foundation or somewhere else and saying, \u201cLet\u2019s figure out a way forward.\u201d And I would just put forward the premise that John\u2019s book is really the first kind of John McDonough: the tough, no-nonsense, exaggerate differences, which I think to some extent misrepresent the people that he attacks.<\/p>\n

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\n\t\t\t\tSTAT Plus: Momentum is building for a big change to how doctors get paid<\/a><\/p>\n

But when I went to the end of the book and read the way forward, I couldn\u2019t disagree with much of it. And so I felt at the end that there is a lot of opportunity for moving forward. I wouldn\u2019t like this debate or John\u2019s book to overshadow that, because it\u2019s gotta happen. It\u2019s not gonna be with people who think Trump is the most fantastic president there\u2019s ever been, but it\u2019s also gonna be with people who think of themselves as conservatives or neoliberals, in John\u2019s phrasing.<\/p>\n

Bosch: I love that as a setup for this conversation because I do think it\u2019s really important to bring together people who respect each other and agree on certain values and disagree about how to do it. I think that\u2019s where we\u2019re more likely to get actual productive conversation instead of just the shouting that we seem to see so much.<\/p>\n

So John, so what is, in as few sentences as possible, the ultimate argument that you\u2019re making in the book?<\/p>\n

McDonough: So the ultimate argument is that Americans are deeply distressed these days about so many aspects of our health and medical care system. The requirements for approvals before you can get services, the large and harmful cost sharing, deductibles, copays, coinsurance, the mountain of consumer medical debt and medical bankruptcy, the fast-rising premiums on the commercial side, what many people see as the invasion of private equity financing into the medical system, taking over hospitals, nursing homes, medical practices, veterinarian services, plus the extraordinary amount of consolidation and monopolization we\u2019ve seen in so many parts of the economy and so much in in medical care as well.<\/p>\n

Most people have heard about one, two, three, or all of these things. And I think for the most part, people look at them as discrete phenomena. And what has occurred to me in writing my book is that they are actually all interconnected.<\/p>\n

And the thread that interconnects them is the term neoliberalism, which was a political economic movement that has roots in the \u201930s and in the 1940s. It was kind of a fringe movement for a long time, with leaders such as Milton Friedman.<\/p>\n

In the \u201970s, when the New Deal era came to an exhausted end with the election of President Reagan, we entered a new economic political era that Ronald Reagan exemplified and he was the prime seller of in the United States, along with many others around the world. This was an international movement: Maggie Thatcher in Great Britain, Gerhard Schr\u00f6der in Germany, Deng Xiaoping in China, all connected to it in various ways.<\/p>\n

Neoliberalism wasn\u2019t aimed at trying to change health and medical care so much in the United States. But because health and medical care are so vast and big, it\u2019s preposterous to imagine that we could have all that societal change and medical care would just go unscathed. So my conclusion is that if you want to understand how we got to where we are now, you have to understand the neoliberal movement of that era.<\/p>\n

I dislike a lot of their ideas, and I respect the commitment, the power, and the guts that these people had to go out into the hailstorm and shout their ideas to the rafters and then see many, many of them implemented. It was a revolution. The premise of my book is if you want to understand why we are in the sorry state we are now, you have to go back to the roots, understand this, and see how it unfolded over what I call the four decades of U.S. neoliberalism between 1980 and 2020.<\/p>\n

Bosch: Stuart, on a scale of one to 10, how much do you agree with that premise? Let\u2019s say one is not at all, ten is we\u2019re in sync.<\/p>\n

Butler: I agree with John\u2019s opening points about the kinds of concerns that we have. The patient confusion, debt. \u00a0No question about it. In a country like this, a country as advanced and as rich as we are, the fact that there are millions of people who cannot get access to adequate health care is first of all ludicrous and outrageous.<\/p>\n

The question, and John of course posits an answer to this question, is: Who\u2019s the cause of this? and that\u2019s where I think we\u2019re going to fundamentally disagree. First of all, I have to plead guilty to being what John would call a neoliberal and a fan of Milton Friedman. I was really brought up in my formative years at university and thereafter on Milton Friedman, and met him several times actually, and remain a great fan of his. And I think what John does in this book, unfortunately, is to exaggerate and often misrepresent the core underlying values and objectives of the so-called neoliberals. \u201cNeoliberalism\u201d is a term that I would be comfortable with, because I think of liberalism in the European sense of freedom and respect for people as the core of it.<\/p>\n

Just to give you one example, I think John does misrepresent very much the idea of monopoly and laissez-faire capitalism. Neoliberals have always been concerned about monopoly, about the producer having control over the customer. Neoliberalism is very much a kind of \u201ctrust the people,\u201d or a people-first approach. It challenges government provision when it\u2019s monopolistic, as when I was brought up in the U.K. and had lived for 30 years under a monopolistic government-organized system. And now I\u2019ve lived under a rather different system, but still the concern with monopoly, of decisions being made in backrooms, whether for profit or to cut budgets or for whatever \u2014 these are not unique to private provision.<\/p>\n

When we think about the way forward, and as I said, when I look at John\u2019s book, I\u2019m drawn to many of the recommendations at the end, because I do think that whether it be private monopolies or public monopolies, these actions are needed.<\/p>\n

But I think it\u2019s really important that we don\u2019t let John convince the public that people who call themselves neoliberals are perfectly fine with people profiteering out of the illness of others and ganging up on the public and patients. This is very much an argument about tools and techniques, what I call engineering issues, rather than a deep philosophical difference.<\/p>\n

McDonough: I accept that monopoly\/antitrust is a great place to start. It\u2019s so important, and urgent. We see it playing out every day in American society with Disney and Paramount and Live Nation and all the rest. It\u2019s all around us. It started in the U.S. around 1890 with the Sherman Antitrust Act in terms of government involvement. The purpose of antitrust was to prevent companies from getting too large by taking over companies and swallowing them up and thwarting competition. And that, with fits and starts, ups and downs, changed little over roughly 90 years.<\/p>\n

Butler: Right.<\/p>\n

McDonough: That was the direction and the consensus in the U.S. Dwight Eisenhower took credit for all the antitrust cases he brought when he was president and running for re-election in \u201956. It was a bipartisan thing. Even in the early days of neoliberalism, Milton Friedman said, the one area I believe that government has to step in and control, like it or not, is to thwart monopoly and antitrust.<\/p>\n

But there was a switch that happened in the \u201950s at the University of Chicago, where Friedman was based. Aaron Director<\/a> and other folks adopted a shift on antitrust. And one of their students by the name of Robert Bork, took on the mantle that we need to reorient antitrust in the United States. He put his thoughts into a book that became quite popular, particularly on the conservative side, called \u201cThe Antitrust Paradox.\u201d His premise was: We\u2019ve got antitrust all wrong. The notion that big is always bad is not true. If somebody gets big, that\u2019s because they deserve it because they won in the marketplace. Leave them alone and let the market take care of them.<\/p>\n

That idea spread substantially, and Friedman bought into it as well. He switched at some point. With Reagan\u2019s election, they used Bork\u2019s consumer welfare hypothesis: As long as two companies wanting to merge can prove that it will result in lower prices for some consumers, it should get a green light. They should be able to do pretty much what they want if they can show that. So in 1981 and \u201982, the new Reagan administration completely rewrote the antitrust guidelines, the federal guidelines that instruct federal judges and prosecutors, state attorneys generals, everybody. Here\u2019s how we see the world. And this was the most dramatic rewrite of those guidelines ever and embodied the consumer welfare hypothesis.<\/p>\n

That led to a significant drop in antitrust activity and a significant going to sleep on many levels, including in medical care where we\u2019ve seen a massive amount of mergers and acquisitions since then. Many economists today look at the health care sector, and their conclusion is if you want to understand why health care is so expensive in the United States right now, it is because of the extraordinary amount of monopolization and antitrust.<\/p>\n

Today, in over 90% of counties across the U.S., the hospital sector is rated as highly concentrated, the highest rating you can get from the Herfindahl-Hirschman Index, the HHI. That\u2019s my reading of it. There was a revolution and the neoliberals won.<\/p>\n

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\t\t\t\t\t\tHospital and pharmaceutical prices are smothering America\u2019s businesses<\/a><\/p>\n

What did I miss in my reading of history here, Stuart?<\/p>\n

Butler: Well, let me try to fill in the gaps that you have in your understanding and knowledge. I think the antitrust issue really is a perfect example of what I was saying earlier, which is that on the principles and objectives maybe we completely have a broad agreement. And there becomes debate about the engineering of how you get there.<\/p>\n

I think the antitrust evolution of neoliberals is a good example of that. The bottom line of Milton Friedman and other supporters of neoliberalism was that there has to be effective competition, there has to be open entry. In other words, there shouldn\u2019t be barriers to people coming in to try to do a better job to deliver for the consumer or the patient in this particular case. As John well knows and says in his book, in the early Friedman years the feeling was that antitrust was the most effective tool and was the critical tool to do that. And on that was there was board agreement.<\/p>\n

Then what you see is Friedman and others saying, wait a minute, we might have been ignoring the political game that goes on around this, because what was happening, he said, was that you see the people who are currently providing start to manipulate the Antitrust Act to favor their position and in fact use their good relations with government, close relations with government, to get government to come down on their side of these debates.<\/p>\n

Friedman\u2019s position was not that that monopoly was suddenly OK. It was that the antitrust system had basically been corrupted. And that\u2019s why he opposed it, not because he wanted to see more monopoly. And in fact, if you look at the people today who would be called Friedmanites, think of, you know, people like Jim Capretta, the Milton Friedman chair at the American Enterprise Institute. You can\u2019t get more Friedmanite than that. They say, yes, the arguments against, or the weaknesses of, antitrust that Friedman and others and Bork identified were valid. And we\u2019ve got to look at other tools, better tools to achieve the objective of open entry, and real competition, and so on.<\/p>\n

You\u2019re very familiar with this Certificate of Need requirement that in many communities says, \u201cwell, if we\u2019ve got enough hospital beds, we\u2019re not gonna let anybody else come in and compete or build.\u201d That is so antithetical to open entry and leads to monopoly. So they attack things like that. Or licensing, which yes, to some extent will preserve the quality of services, but on the other hand, we all know is used to shut out people who can deliver services to people at lower cost. And so we see this in so many areas of the industry. So I think it is in fact a good example of how people\u2019s position can change and mine has changed. I know John has changed. When you see the engineering that you thought would lead to a good result doesn\u2019t, and you\u2019ve got to change it. And that\u2019s what we see in this case.<\/p>\n

But there remains agreement on the principle. I am totally in favor of universal access \u2014 not only a mandate because I think that\u2019s only one element and there\u2019s certain reasons for that. But I support subsidies. Milton Friedman was a big supporter of subsidizing people to enable them to get an adequate level as determined by society, by the political process, whether it be welfare or education or health care. So there was agreement on this. What happened over time were debates about how you get there.<\/p>\n

And that\u2019s why I think again, I was heartened by the last chapter of the book. We can argue about some elements of that, but broadly I agree. And so let\u2019s get together and start looking for tools and techniques to get us there. And I know John wants to do this and has always done it. And that\u2019s what we tried to do in Massachusetts and to a large extent with the Affordable Care Act.<\/p>\n

McDonough: So let\u2019s switch to another topic of equal urgency and importance. And this was Friedman\u2019s hypothesis laid out in a New York Times op-ed<\/a> on Sept. 13, 1970, where he said it in his inimitable all-or-nothing fashion: The sole duty of the for-profit corporation is return on equity to shareholders and nothing else. Any sense of obligation to customers, to patients, to communities, to workers is simply a myth. The CEO should look in the mirror every day and say, \u201cWhat can I do today to make more money for my shareholders?\u201d<\/p>\n

I call it the most influential op-ed there\u2019s ever been in American history. And my evidence is that 50 years later, the New York Times had in its Sunday edition an eight-page pullout special section<\/a> that was simply a reprint of Friedman\u2019s op-ed with commentary from about 25 economists, Nobel Prize winners, political people, others commenting on it, and I\u2019d say overwhelmingly most of them commenting on what they found wrong and objectionable.<\/p>\n

That idea became known as MSV, or maximizing shareholder value. It became enormously influential in corporate America, in business schools, in changing people\u2019s mind about how they think the corporation fits into American society. Through one of Friedman\u2019s acolytes, Michael Jensen<\/a>, it led to the notion that we should stop paying salaries to CEOs and we should pay them in stock options instead so that they would look in the mirror and say, \u201cWhat can I do for the shareholders?\u201d And they\u2019re looking at and for themselves as well.<\/p>\n

Today, about 80% of compensation in large corporations is not in salary, it\u2019s in stock options. And it\u2019s led to all kinds of manipulation with stock buybacks and other kinds of things.<\/p>\n

But it was a place where Friedman was particularly influential. I would argue, and I argue in the book, that his thinking became the intellectual foundation of what we know today as private equity, where now we have organizations, a large part of the American economy, totally dedicated to the proposition that \u201cwe are out to make as much money as we can,\u201d uniting shareholders and managers together as quickly as possible, five to seven years, and then moving on to our next conquest. It was a powerful idea, and he was incredibly effective at promoting it and I would argue in a way that has been quite damaging to American society.<\/p>\n

Butler: Well, let me try to respond to that without having all this in front of me. I know John has a photographic memory, so he can probably immediately spot these things. But I think that\u2019s another interesting example of where you\u2019ve got to look at first of all at the context of that op-ed and that debate, which was whether corporations should have a public purpose, and should the managers of corporations pursue those purposes, whether or not the shareholders approve of it or if it is in the interests of shareholders. That\u2019s the origin of that debate.<\/p>\n

Now first of all, we don\u2019t need to spend time on that. I think that there are areas where Friedman and others went too far. And we can talk about private equity and I don\u2019t think John and I are going to be disagreeing too much about that.<\/p>\n

But let\u2019s just recall that that was the context. And then when you dig in to Friedman\u2019s and others\u2019 views, including Friedrich Hayek, who is the kind of intellectual grandfather in a way, or father of Friedman, the view was that corporations, and business people generally, that seeking profits at the expense of anybody else was not and should not be their public purpose. Their view was that corporations certainly did have other objectives and Milton Friedman and Hayek and others all felt that profits cannot or should not be used to evade the law. So all corporations should be subject to laws. Also, they should be subject to what one might call the common values and culture of the society, just like anybody should within a community. A community has values and notions of rights and obligations. And as shareholders and as managers of corporations, those individuals have the same.<\/p>\n

So I think John is, in a sense, technically correct that the argument was made that rewarding the shareholders should be the one and only objective, and that\u2019s to a large extent what Friedman said. What that really included, however, was the obligations and values of the community that the shareholders had or should have, should be guiding those decisions as well. So the idea that that Friedman and others were saying just, \u201clet\u2019s profit, and grind down everybody, ignore everybody\u2019s rights and so on\u201d \u2014 that\u2019s nonsense, to be frank about it. That\u2019s not where neoliberals are and never really have been.<\/p>\n

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But I would agree that the impact of that debate and that language led to many people taking the view that all that matters is profits. And there are many of them around today, and we know many of the names of those people.<\/p>\n

Bosch: This history is so fascinating, especially the way that you two agree on many parts of it and disagree sort of on the effects and what it means. So I\u2019m curious how your different understandings of this history connect to what you think needs to happen to the US health care system now. So, John, what does the way you understand this history mean for how you recommend health care move forward?<\/p>\n

McDonough: I react by putting together both of the prior things that we talked about, monopoly and antitrust, and maximizing shareholder value and private equity. Look at what we\u2019ve gotten today with the financialization of U.S. medical care and the corporatization of it in ways that shifted its focus away from communities. So we see that hospitals are increasingly less local. They are local because they\u2019re in communities, but chances are they\u2019re owned by somebody far away in New York or some other part of the country where they own dozens or hundreds of hospitals.<\/p>\n

The local control is missing and the local responsibility diminishes significantly. And the people who run the institutions see themselves more as business people who are out for financial returns for themselves and others. You can see this disconnection that erodes the essential trust that people used to feel in medical care. In my book\u2019s last chapter, I refer to Gallup polls looking at trust across American society. If you go back to 1975, 79% of Americans said they trusted American medical care \u201ca great deal or quite a lot\u201d to do the right thing. Today, that same number is around 28%. It\u2019s not just medical care, it\u2019s across society. People just don\u2019t have the same degree of trust that they used to. And it\u2019s not irrational fear. Changes in the American body politic about the role and responsibility of business, there is a diminishment in feeling that \u201cthey really are for us.\u201d We saw in this election in Kansas a sitting U.S. senator did so much aggressive bill collecting<\/a> from former patients, his OB-GYN patients and so forth. We see those stories all the time about the impact of medical debt on people unable to pay their bills getting their cars seized, getting their wages attached. We see this erosion of a sense of brotherhood and sisterhood in the sense of \u201cwe\u2019re a nation together.\u201d<\/p>\n

We have to figure this out: What can we do to restore trust in U.S. medical care? With regards to private equity, I don\u2019t propose to chase private equity out of U.S. medical care because it\u2019s not realistic. But I don\u2019t think they have any business being involved in organizations that provide direct care to patients if they\u2019re patient-facing. We should move toward a withdrawal of that. It would clearly take time and have lots of repercussions. But there\u2019s gotta be a better way to do this than leave people to the mercies of the market when the market has no mercy.<\/p>\n

Butler: Well, other than the last sentence or two, I probably agree 98% with what John just said. I get to that position based on what I said earlier, and what I attribute to the views of neoliberals, including people like Milton Friedman, which is that community values and the idea of rights and the patient comes first, the customer comes first, and that has got to be the test we apply to something like private equity. I feel, and I know John feels the same way, that health care, and particularly public health in a community, is a community venture. It should reflect the community, both the challenges of the community and the desires to a large extent of people within that community. So we totally agree on that. And we totally agree that when you\u2019re in Tennessee, if the decisions about what goes on in your health care are made by a bunch of people in New York who are seeking to maximize their return, it\u2019s probably not going to turn out well. I totally agree that we\u2019ve got to make investments in health care shaped and controlled by local values and objectives. I totally agree. And John knows this. And I\u2019ve been very interested in social determinants of health, on how do you build community institutions to shape health, to recognize that health is not only medical care, but a lot of other things, such as housing.<\/p>\n

McDonough: I would second that. Stuart left the Heritage Foundation, I think in 2014, and is now at Brookings and has done incredibly important writing in the Journal of the American Medical Association, diving deeply into social determinants of health, and in particular, how to understand it from a conservative perspective, that it makes sense. It\u2019s such important work.<\/p>\n

Butler: I know you agree with that in part. I think it overlaps. I think we may use different words and so forth, but the intent is the same. That\u2019s why I talk about \u201cengineering arguments\u201d so much. Now, that said, let\u2019s look a little bit more at private equity. One of the interesting things about investors in high risk areas willing to put capital into risky ventures is that they have been and can be very effective at enabling ideas, new ways of doing things, to have a chance to succeed when more traditional investment, including local investment, would not tend to do that. Think about the patron of the arts from the Renaissance onwards. You know, we would have much poorer art to go and look at in our national galleries if there weren\u2019t really rich people who just wanted to see certain kinds of art supported. And I think the key as we look forward is how can we get people who are willing to take high risks with their capital, which is what to a large extent we\u2019re talking about with private equity \u2014 to have that as an important element but not one that is the overriding feature of the capitalization. Are there different kinds of nursing homes that could be much more effective and efficient and also provide more satisfaction for people who are growing older? I\u2019d be looking probably more towards private equity for those if we could figure out how to do that as a test venture, like a wildcat oil driller from decades ago, right? You want to try to get people who are open to high-risk, high-return capital. So I think it has a role.<\/p>\n

But I\u2019m not naive at all in agreeing with John that when that becomes the overriding nature of capital in health care, we\u2019ve got a big problem. We do. So we\u2019ve got to drive forward in that way.<\/p>\n

McDonough: I hate to do it, but I have to another complaint about Milton Friedman. I would have loved to meet him and talk with him. I\u2019m sure we would have had a great time. But so much of his presentation is very much black or white. So he says, you\u2019re either for economic freedom, or you\u2019re for equality, and you have to pick one. You can\u2019t have both. You\u2019ve got to be focused on the shareholder and nothing else. And it was very effective in terms of his advocacy efforts. And it ignores someone like Stuart. I look at Stuart and this is a man of grays. This is not a man of blacks or whites. This is a man who sees the who sees the shades inside.<\/p>\n

Butler: Yes, I agree.<\/p>\n

McDonough: And private equity is the personification of maximizing shareholder value. You go in there, you\u2019re only in there for five to seven years, and then you get out of Dodge as fast as you can with your bags of cash and hoping to find the next sucker to take it over. And we thought they were taking over really risky hospitals, and it turns out from folks who\u2019ve analyzed this closely, they have not been doing that. They go after middle range organizations that have some money and some value where they can go in there and take their real estate and sell it to a real estate investment trust, get rich really fast, and then skate out of town. And so yeah, I think private equity could have been a lot more productive and helpful if it had had some guardrails around it.<\/p>\n

But we accepted this notion, just let the business people run wild because they know what they\u2019re doing. It turned out to be a fatal error in so many, many, many situations.<\/p>\n

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\t\t\t\t\t\tHow health care costs are undermining America\u2019s public-sector employers<\/a><\/p>\n

Butler: I think I\u2019ve acknowledged that consequence. But I\u2019d like to just say a few things about Milton Friedman as a public economist. Because I think I said at the very beginning that I was very much brought up on Milton Friedman when I was at university in Britain. And I can assure you, most people in universities in Britain in the 1960s and early \u201970s were not neoliberals. And Milton Friedman, in contrast with, say, Hayek and some of the other economists who shared his view, was very much a public economist. He wrote columns for Newsweek. He was on television and so on. He saw his role as shaking up people\u2019s thinking. And he portrayed things as black and white \u2014 I would argue that your book, John, is a black and white book. You don\u2019t have to answer that, but that\u2019s my feeling. <\/p>\n

But Milton Friedman was very much a black and white advocate because he wanted to shake things up and get people to think. Monopolies in the public sector are in some ways worse, he would argue. That\u2019s the kind of thing he would say, blunt, to the point. And then you have to kind of argue your way to the right position between those blunt positions. So I think it\u2019s important to appreciate that the language of op-eds, even the language of books, the language of television, is short attention span, it\u2019s hitting people over the head with an idea, rather than saying, \u201cThis is a complicated idea.\u201d \u201cSo on the one hand, on the other hand.\u201d The New York Times doesn\u2019t want an op-ed like that. It wants you to go straight for the throat or straight for the high ground and stay with it.<\/p>\n

So I just think it\u2019s important to put that on the table and say that. And I\u2019ve done the same myself. I\u2019ve written pieces that overstate an argument. And sometimes I\u2019m upset that people have taken my words precisely and used them. And you\u2019ve pointed that out in your book occasionally with things that I\u2019ve written that I probably should have been a little bit more nuanced. I think that is the game of how you change opinion. And Friedman had a very particular role in this. But I do think it\u2019s important not to paint everybody who takes the basic neoliberal positions that Friedman and his earlier supporters took as being unsubtle. It\u2019s making a simplified argument. And I wish people noted that I\u2019ve changed my mind, like Friedman, on antitrust and so on. It\u2019s important to see that as part of the equation.<\/p>\n

That\u2019s why that\u2019s why I\u2019m actually relatively optimistic about the future because like I said I think John\u2019s final chapter and my views, I really don\u2019t disagree a lot with this. We might disagree about how to get there or I might fault some of the language, but I\u2019m broadly in agreement.<\/p>\n

And I think now, in what I hope will be the post-Trump era, I think people like us have to clear away the misunderstandings and the overstating of positions and say: How can we actually get out of where we are? Because we actually do agree on where we want to end up. There\u2019s not really a lot of disagreement about values and principles. There may be intense disagreement about what tools we think will get there. And that\u2019s a fair debate. And it\u2019s not a personal debate.<\/p>\n

McDonough: So that that brings us back in history, but a little closer to today, because in some ways where we are right now feels a lot like 2005 and 2006, when we were looking ahead to a national administration change and a need for significant and substantial health care reform. We went into that in 2005 and 2006 with lots of bipartisan groupings, with multisector groups looking at Massachusetts and other models. And it was quite intensive. I remember Sen. Kennedy, every time I sat with him, the first thing he would say is, \u201cJohn, this is never gonna happen unless it\u2019s bipartisan.\u201d He said it over and over. And of course, it happened though it was not bipartisan. The Affordable Care Act was a strictly partisan piece at the end, not because people didn\u2019t try, like you and others, to bring folks together.<\/p>\n

So the question is: Can we learn anything from that experience to avoid a replay of that same ball game in 2027, \u201928, \u201929, and \u201930?<\/p>\n

Butler: I very much hope so and I think it\u2019s possible. In fact, in the last piece I did for JAMA<\/a>, I reminisced about the good old days where people did actually talk about ideas. Ted Kennedy would bring in Orrin Hatch and others and me and others, and we would have a conversation. I laid out some ideas in that piece that I think we need to think hard about. Should all the health care subsidies that people get be dependent any more on where you work or if you work? And if we think that way, then you come up with a very different system than we have today. So I think now is the time to put forward those kinds of broad ideas to get people back in the room again. They can go out on the campaign trail and argue with each other, but get back in the room afterward. Open a nice bottle of pinot and start to talk about these things.<\/p>\n

I think we can do it. That\u2019s what I hope will happen. And I think John\u2019s book will make people like me respond. And I think that can then lead us all to say, \u201cOK, let\u2019s dig in further about where is the agreement? How could we think about this moving forward?\u201d It\u2019s urgent, it\u2019s important work.<\/p>\n

Bosch: I think that might be a great note to end on, to be honest. I am so grateful to both of you for this really exciting conversation and hopefully it\u2019ll continue.<\/p>\n

Who do you want to take part in the next Friendly Argument about medicine and health policy? Share your ideas, or volunteer yourself and someone you\u2019d like to debate, by emailing [email\u00a0protected]<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"Welcome to Friendly Argument, a new STAT First Opinion series in which two experts who disagree but respect…\n","protected":false},"author":2,"featured_media":886661,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[59],"tags":[97,252,9149,254,253,3201],"class_list":["post-886660","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health-care","tag-health","tag-health-care","tag-health-care-costs","tag-health-policy","tag-healthcare","tag-private-equity"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/886660","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=886660"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/886660\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/886661"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=886660"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=886660"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=886660"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}