VIDEO: “The luxury of making decisions without thinking about cost is gone”: Lown Institute president Dr. Vikas Saini’s opening address at LOWN26

Welcome! My name is Vikas Saini and I’m president of the Lown Institute.

Thank you all for being here. This day wouldn’t have been possible without the generosity of our sponsors. That includes one incredibly generous Champion who is anonymous — as well as our Changemakers — the Peterson Center on Healthcare, Arnold Ventures, and the Grimshaw-Gudewicz Foundation, our Partners, the American Board of Internal Medicine Foundation and Mr. Breck Eagle, and our ally sponsor, Dr Christian Ramsey. 

I also want to acknowledge the hard work of the Lown staff.  They’re the reason we’re here ready to go. In particular I want to call out Carissa Fu and Grant Sabean, who carried the heavy load of the logistics and planning. But also our whole Comms team — Aaron Toleos, Josh Speiser, Judith Garber, and Brenna Miller — they deserve a big shout out. They were responsible for getting the word out to everyone — and I’d say they were pretty successful since we sold out about a month ago. In fact, we had to rearrange the seating to fit more people in… So if the spacing is a bit awkward, that’s why.

And thanks to the hotel staff and the AV team for helping us keep running smoothly.

For those of you who don’t know us, let me 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 world’s first usable defibrillator and technologies to go with it — like the CCU. But our organization was founded to make sure we put patients over technology. Over the years we’ve convened conferences on low-value care and other key issues. More recently we’ve been publishing the Lown Hospitals Index of Social Responsibility which has gotten noticed. We’ve also been hosting the Bernard Lown Award annually. This dinner — tonight’s will be the fifth — is always a moment to pause and to celebrate inspiring young clinicians who don’t take no for an answer. 

Though the Lown Institute’s work is very specific, our vision is broad. I myself stand before you with an eclectic background. I studied philosophy and history before med school. Over my career, I’ve seen the system from many angles: as the cofounder of a device company that developed new science, navigated Silicon Valley, FDA regulators, and eventually the public markets;  as the founder of a primary care network that negotiated prices and took financial risk; and as a private practitioner trained to do as much as possible for the patient and as little as possible to the patient.  

All of that is in 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. Today we’re lucky to have with us speakers with incredibly broad expertise and varied opinions. So buckle up!

I’m just going to just name check the drivers of the costs of care for reference:
1. It’s the prices!
2. Financialization and monopolies
3. Underinsurance and the lack of a universal system
4. Out of pocket costs
5. The aging population
6. Baumol’s disease: service costs always rise faster than manufacturing costs

And three that are inter-related:
7. Technological innovation
8. Lack of primary care and the dominance of specialty care—which is more expensive when it’s applied indiscriminately.
9. A wide range of low value care

There’s lots to say about each of these, and we don’t have nearly enough time to cover them all. Let me take just a minute to exercise my prerogative and mention a couple of things we probably won’t get to.

Value-based care seems to be slipping from the policy agenda—perhaps more on the left than the right—maybe because there was no magical transformation from prior efforts.  Certainly, the recent debate about CMMI’s WISeR initiative has shed more heat than light in my opinion. 

As a senior citizen who also takes care of a very elderly mom—I can tell you LVC is hiding in plain sight—there’s rarely a medical visit where I don’t see at least one, and sometimes two or three things being done that are marginal at best, and a complete waste of time at worst. A repeated blood test, a hospital admission simply to jump the line for an MRI, a cardiac echo for a really stupid reason —trust me. the list goes on. And that’s just in one month. And that’s at Hahvahd.  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 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 gonna 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 people realize. 

I was once walking through Reagan Airport with my former colleague Shannon Brownlee and we ran into a Congressman, a leader in health care policy. Despite my deep cynicism about Washington, I was still flabbergasted when he said “Yeah, it’s totally messed up — but nobody in this town is going to do a thing about it — they’re all waiting for it to collapse first.” That was 10 years ago.

That time may here. We’re 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 that input costs across the entire economy are about to go up — maybe by a lot, and maybe for a long time. The bond market reacted last week, 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, possibly permanent. 

There’s a lot more to say — but for now, let’s just bookmark that. 

So—Affordability. Trying to talk about it is like interpreting a Rorschach test. Affordability for whom? For patients and families? For the business community? For all of society? 

To me, the crisis of affordability is a crisis of inequality. The K shaped recovery since the COVID lockdowns has meant that people who make a living from their labor are coming up short while the ownership class are partying. When there’s such a basic contradiction between working class income and a winner-take-all casino economy—particularly when people’s health insurance is linked to their employment—something’s gotta give.

Our current trajectory indicates that health care may be about to bifurcate: one for wealthy elites, where no biologically plausible grift is too ridiculous to pursue and then a dystopian one for everybody else, fast-food medicine that’s transactional, confusing, full of AI slop, and complicated.

Two-thirds of adults say they’re worried about being able to afford health care for themselves and their families and now hospital finances are also in danger of cratering.  But even there it’s a tale of two cities — some systems are running their own hedge funds,  others are running on fumes.

Like nothing else, health care acutely manifests the material realities of policy.

There’s a graph I’m sure everyone’s seen—showing life expectancy versus spending across the OECD countries — the one where the US is a huge outlier? Many people still don’t know that that outlier trend only started in 1980.  The fault was not in our stars. It was in our policies. 

Underlying those policies was a worldwide cultural shift—Hollywood took note when Gordon Gekko said “Greed is good”.  In the UK, Margaret Thacher famously said: quote “There is no such thing as society.” And in the US that moment resulted in an explosion of venture capital and private equity investments into healthcare—drugs, devices, services. I witnessed some of that first hand. And whatever a case-by-case  analysis might show—and there were plenty of real home runs—collectively, at scale, the data shows this was a failed experiment. We spent more and more and got less and less. Hundreds of billions, if not trillions of dollars with very modest returns in life expectancy. 

Faced with that data, a serious nation would seriously rethink what innovation in health care actually means, how it should be rewarded, and how it should be regulated. That’s just to say that a lot of people got rich, and are still getting rich, selling 21^st Century snake oil.

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—and inventive—we’ll need new policy tools.

But we’ll also need a new politics—desperately—I mean, I don’t even know what left or right means anymore. I do know that we need new frameworks, new language, strange bed fellows, disruptive ideas, and a willingness to come out of our corners.

We also need a moral compass. One of the most striking traits of Dr. Lown was his humanism. Not some abstract philosophy but something running deep in the marrow. It made him an extraordinary clinician whose patients adored him. The healing power of just being PRESENT with the patient—when you see that in action—it’s like magic. A good delivery system should enable that, not sabotage it. 

In the exam room, it doesn’t matter if a patient is a Democrat, a Republican or an independent — whether they believe in free markets or single payer. What matters is that we’re listened to, understood, and cared for with expertise and dignity. That should be our moral compass, the primary design principle.

I believe we’re entering a period of great turbulence. As the saying goes, usually misattributed to Lenin, there are decades when nothing happens and there are weeks when decades happen.

So as we kick off the day’s proceedings let’s be imaginative and let’s also be charitable. We’re not going to agree on everything, nor are we going to end up with a detailed design for a new delivery system by cocktail hour. (Maybe by the end of cocktail hour? Remember —in Cambridge, psychedelics are tolerated by the authorities.) 

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 is beyond markets? For libertarians: even if markets were fair, how do we avoid the winners using their winnings to undermine the very fairness of those markets?

Progressives need to admit there may be downsides to massive bureaucracy, and one size fits all government mandates in a country as vast and diverse as the US. How do we ensure popular accountability in a Medicare for All system—avoiding 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 health care, 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.

Finally, let me say that for true health, we need to conjure with the deep human need for freedom. The late James Scott has convincingly argued that people have resisted state power since the very first city states in Mesopotamia. While it may be a true that modern forms of freedom only emerged out of the Enlightenment in tandem with the rise of capitalism, couldn’t that freedom be expressed and aggregated in other ways besides a purchase? Can we not imagine new kinds of structures—crowd-sourced integration machines—for transparency, accountability, and, dare I say it, participatory democracy?

Lately, I’ve been trying to imagine something that’s almost impossible to imagine: What might a libertarian, radically decentralized, locally responsive yet publicly controlled Medicare for All delivery system look like?  Can the genius of America invent that?

I’m actually optimistic about what this moment holds. As Gerry Anderson at Hopkins has been saying lately, we are about due for a new 15-year cycle of reform in health care. But this time I see it coinciding with a supercycle of new thinking about political economy.

One thing 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. A fancier 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 being debated. Imagine a path forward and then imagine your own place on it. You can start by answering a couple of questions: First, it’s 2040 and the US has made health care affordable for all. What 3 things did we do to get there? And second, What can you do now to start on that path? You can post your answers with stickie notes on the posters outside, or record them in the video booth at cocktail hour, or share them with us during the table top exercise in the last session of the day.

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. 

And as JFK said in 1962: “We choose to go to the moon not because it is easy, but because it is hard.” 

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 health care. Why not start it right here? Why not start it right now? 

Thank you all for being here.