VIDEO: Lown Institute president Dr. Vikas Saini’s opening address at LOWN26
At the opening of the LOWN26 conference on healthcare affordability, Lown Institute president Dr. Vikas Saini invites attendees to “engage with each other and with the ideas that we’re going to air and debate today and imagine a path forward and then imagine your own place on it.”
“For true health, we need to conjure with a very deep human need and that’s a human need for freedom.”
Dr. Vikas Saini
My name is Vikas Saini. I am president of the Lown Institute. It is delightful to have you all here. Thank you for being here.
For those of you who don’t know us, let me just tell you a little bit about the Lown Institute. We were founded in 1973 by Dr. Bernard Lown. He was a Harvard cardiologist who developed the first usable defibrillator which, in the language of today, went viral in about four to six months worldwide. And also a bunch of technologies that went with it including the basics of the coronary care unit. In fact he he built the first coronary care unit in Boston. In fact, he had to persuade the people building the Brigham that this was a good idea and he had to raise his own money to get it built. But this organization, the Lown Institute, was founded primarily to make sure we put patients over technology. So, that’s who we are.
And over the years, we’ve convened conferences on low value care and other key issues. And more recently, we’ve been publishing the Lown Hospitals Index that you heard about hospitals index for social responsibility because we thought there’s another lens with which to look at these questions. We’ve also been hosting the Bernard Lown Award dinner annually and tonight’s dinner will be the fifth. It’s always a moment to pause and really celebrate inspiring young clinicians who don’t take no for an answer. So, Dr. Chanelle Diaz will be the honoree tonight and we look forward to that ceremony as well.
The Lown Institute’s work is quite specific, but our vision is very broad. I myself stand before you with a fairly eclectic background. I studied philosophy and history before I went to med school. And then in my career, I’ve seen the health system from many different angles as the co-founder of a medical device company that developed new science, navigated Silicon Valley, dealt with FDA regulators, and eventually the public markets. as the founder of a primary care network that took financial risk, negotiated prices and tried to eliminate waste, and as a private practitioner in cardiology trained by Dr. Lown to do as much as possible for the patient and as little as possible to the patient. So that’s who we are. That’s the DNA of our organization.
Today we’re here to talk about affordability. We started planning this last summer and the issue hasn’t stopped growing as you all know. And we’re lucky to have a lot of speakers here with incredibly broad expertise and a lot of varied opinions. So, buckle up.
I’m just going to name a few of the drivers of the cost of care just as a reference point for all of us. This is almost a chant. So, it’s the prices stupid. It’s financialization. No, it’s monopolies. No, it’s underinsurance. It’s the lack of universal coverage. Why don’t we have single-payer? It’s out-of-pocket costs. It’s the aging population. It’s Baumol’s disease. Service sector prices always go up above average because manufacturing prices decline. We’re doomed to this. And then three that are interrelated. Technological innovation. How could that be a bad thing? Also, lack of primary care and specialty dominance, which is inherently more expensive when it’s used indiscriminately. And last, but not least, an amalgam of all of the above is a wide range of low value care.
Now, there’s a lot to say about each of these. I certainly don’t have the time and throughout the day we’re not going to be able to cover all of this. But I am going to exercise my prerogative and just take a few minutes to say a couple of things that are that are bugging me. So value-based care seems to be slipping a little from the policy agenda. Perhaps more on the left than the right. Maybe because there was no magical transformation from our prior efforts. Certainly, this is just my opinion. The recent debate about CMMI’s WISER initiative, I think, has shed a lot more heat than it has shed light on this situation. But I’ve got to say, as a senior citizen who takes care of a very elderly mom, I can tell you that low value care is hiding in plain sight. There’s rarely a medical visit where I don’t see at least one, sometimes two, sometimes three things that are marginal at best and a complete waste of time at worst. You know, I’m talking about: a repeated blood test, a hospital admission to jump the line to get an MRI, a cardiac echo for a really stupid reason, trust me. And the list goes on. And this is just in one month and this is at Harvard.
Low value care is everywhere you look if you care to look. That’s not to say solutions are easy. In fact, they’re hard. But I do think the luxury of decision making without thinking about cost is gone because the historical moment we’re in is new. To fix things, we’re going to have to go deeper. We have to do everything everywhere all at once. Not incrementally, but at scale because our runway is much shorter than most people realized. Obviously, this is just my opinion, but I think there’s a seriousness here.
I was once walking through Reagan airport with my former colleague Shannon Brownley. Many of you will know her. And we ran into a congressman. I’m not going to name the name, but he was a leader in healthcare policy. And despite my deep cynicism about Washington, I was astounded when I heard him say, “Yeah, it’s totally messed up, but nobody in this town’s going to do a thing about it. They’re all just waiting for it to crash and burn first.” That was 10 years ago. So, that time may be approaching.
We’re certainly facing economic disruptions like we haven’t seen in decades. The war on Iran, perhaps the biggest strategic mistake in American history, is poised to become a major economic inflection point. We do know input costs across the entire economy are about to go up in the next few weeks and months, maybe by a lot and maybe for a long time. Last week, the bond market reacted, but I doubt it’s done. Which means servicing the federal debt is likely to become an even bigger issue.
In other words, for working people, the affordability crisis threatens to get worse, not better, and longer, hopefully not permanent. There’s a lot more to say about that, but you know, I’m an opinionated guy. I’ll just let’s just bookmark that.
Affordability, trying to talk about it, is like trying to interpret a Rorschach test. Affordability for whom? Is it for patients? Is it for families? Is it for businesses? Is it for all of society?
To me, the crisis of affordability is a crisis of inequality. The K-shaped recovery that we’re seeing since the COVID lockdowns has meant that people who make a living from their labor are really struggling while those who own assets are doing well. Dare I say some of them are partying like it’s 1999. When there’s such a basic contradiction between working-class income and a winner take all casino economy, particularly when people’s health is tied to employment, something’s got to give.
Well, right now the current trajectory suggests to me that the healthcare system may be about to bifurcate. one for wealthy elites where there’s no biologically plausible grift that’s too ridiculous to pursue and then a dystopian one for everyone else kind of fast food medicine that’s transactional confusing complex increasingly full of AI slop and more. So it’s no surprise when our friends at KFF report that two thirds of adults are worried about being able to afford healthcare for themselves and their families.
And now, and we’ll probably hear some of this later today, hospital finances are also under enormous stress. I mean, dare I say, they’re in danger of cratering in some cases. But even there, it’s a tale of two cities. Some systems are running their own hedge funds. Others are running on fumes. So like nothing else, healthcare acutely manifests the material realities of policy.
There’s a graph, I’m sure everyone’s seen it, showing life expectancy versus spending across the OECD countries. The one where everybody’s here and the US is way over here as an outlier. Many people still haven’t looked at that over time and don’t know that that outlier trend wasn’t always there. It started around 1980. The fault was not in our stars. The fault was in our policies.
Now underlying those policies then was a worldwide cultural shift. Hollywood certainly took note when Gordon Gecko said, “Greed is good.” In the UK, Margaret Thatcher famously said, and I quote, “There is no such thing as society.” And in the US, that moment, that whole period resulted in an explosion of venture capital, private equity and other investments in healthcare, drugs, devices, services. I witnessed some of that firsthand.
And whatever a case-by-case analysis might show, and there were plenty of home runs, don’t get me wrong, collectively at scale, the data shows that this that graph shows that this was a failed experiment. We spent more and more and got less and less life expectancy, hundreds of billions, if not trillions. I think that’s a good B school case to to look at with very modest returns on life expectancy. Faced with that kind of data, a serious nation would seriously rethink what innovation in healthcare actually means, how it should be rewarded, how it should be regulated. That’s just to say a lot of people got rich and are still getting rich selling 21st century snake oil.
Now, we should have no illusions about the challenges we face. Like all the great crises of history, to emerge on the other side, people need to be resolute. They need to be inventive. And we’re going to need new policy tools. But I think we also need a new politics desperately. I mean, genuinely, I don’t even know what it is to be left or right anymore, capitalist or socialist. I mean, it’s scrambled. And I think we need new frameworks. We need new language, strange bedfellows, disruptive ideas, and a willingness to come out of our corners, which is kind of the theme of this conference.
But let me just hasten to add, we do need a moral compass. And one of the most striking traits of Dr. Bernard Lown was his humanism. Not an abstract philosophy, but something running deep in the marrow. It just made him extraordinary as a clinicians whose whose patients adored him. I mean, I saw this. I’m not kidding. The healing power of just being present with the patient, when you see that in action, it’s like magic. And a good delivery system should enable that, not sabotage it.
So, in the exam room, it doesn’t matter if the patient’s a Democrat or a Republican or an independent or a single-payer advocate or a free market advocate. What matters is that we’re listened to. We’re understood. We’re cared for with expertise and dignity. And that should be our moral compass and the primary design principle of any reform.
I believe, as I probably have indicated, that we’re entering a period of great turbulence. I think we’re not seeing it all yet, but I think it’s coming. As the saying goes, usually misattributed to Lenin, there are decades where nothing happens and then weeks when decades happen. And we’re kind of entering a period like that.
As we kick off the day’s proceedings, let’s be imaginative. The sky’s is the limit, but let’s also be charitable. We’re not going to agree on everything, nor are we going to end up with a detailed design of a new delivery system by cocktail hour. Maybe by the end of cocktail hour, we’ll have it. And remember, this is Cambridge where psychedelics are tolerated.
But seriously, one thing we might do is identify the landmarks and see where we agree. For example, for conservatives, how much of a social commons is there beyond markets? For libertarians, even if markets were fair and open and functioning, how do we avoid the winners, using their winnings to undermine the very fairness of those markets? Progressives, I think, need to admit there may be downsides to massive bureaucracy and a one-size-fits-all government mandate in a country as vast and diverse as the United States. which is not to say we’re going to have different healthcare in the south and the northeast, but we kind of have that already.
But really the question is: How do we ensure popular accountability especially in something like a Medicare for all system? How do we in such a system avoid author authoritarian government commissars or regulatory capture by the medical industrial complex or simply breaking the national bank? And if we really care about health instead of healthcare, health that’s genuine flourishing, we simply cannot look away from issues of equity and injustice, racism, class contempt, structural injustice. They haven’t gone away and they’re not going to go away unless we do something.
Finally, let me just say that for true health, we need to conjure with a very deep human need and that’s a human need for freedom.
The late James Scott, I think he was at Yale by the end, but convincingly has argued that people have resisted state power since the very first states in Mesopotamia. And while it may be true that modern forms of freedom emerged out of the enlightenment at the same time that capitalism emerged, couldn’t that freedom be expressed and aggregated in other ways besides a purchase? Can we not imagine new kinds of structures? Call them crowdsourced integration machines which is a clunker but but something like that for transparency accountability and dare I say participatory democracy.
Lately, I’ve been trying to imagine something that’s almost impossible to imagine, which is what might a libertarian, radically decentralized, locally responsive, but publicly controlled Medicare for all delivery system look like? Can the genius of America invent that?
Despite everything, I’m actually optimistic about what this moment holds. As Jerry Anderson, who some of you may know at Hopkins, has been saying lately, we’re about due for a new 15-year cycle of healthcare reform. But this time, I see it coinciding with a kind of super cycle of new thinking about political economy. One thing that we do know is that whatever we choose has to be politically sustainable. The new politics will need to be a kind of super majoritarian politics of material conditions, which is just a fancy ass way of saying it’s the economy, stupid.
So, as we get started, I invite you to engage with each other and with the ideas that we’re going to air and debate today and imagine a path forward and then imagine your own place on it. You could start by answering a couple of questions.
First, it’s 2040 and the US has made healthcare affordable. We’ve solved it. What three things did we do to get there? And then second, what could you do now to get us started on that path? Where you live, where you work? And you can post those answers. I think we have a poster board outside and some sticky notes. So, feel free to do that. You can also record them. We’re going to have a video booth that Josh Speiser is going to be running. So, you can do that during cocktail hour after you’ve had one to sort of loosen the tongue. You can also share them during our tabletop exercise in the last session.
Business as usual is simply not going to be a viable option. Instead, we have to imagine and then build new models. We need a paradigm shift, a moonshot. As JFK said in 1962, and I remember hearing this, “We choose to go to the moon not because it’s easy, but because it’s hard.”
So, if we embrace that spirit, there’s an American revival in our future. A revival that few are expecting. A revival that can start in healthcare. Why not start it right here? And why not start it right now? Thank you all for being here.