Conducted and Transcribed by Elise S. Van Scoy (SC ‘20), Project Manager
Abner Mason is a Harvard graduate and the founder and CEO of ConsejoSano, a multicultural patient engagement and healthcare solutions technology company. He previously served as International Committee Chairman for the Presidential Advisory Council on HIV/AIDS and executive director of AIDS Responsibility Project. He also spent twelve years working in government in Massachusetts including working as Chief Policy Advisor to Massachusetts Governors Paul Cellucci and Jane Swift. Before establishing ConsejoSano, Mason founded the Workplace Wellness Council of Mexico, a leading corporate wellness company. CJLPP interviewed Mr. Mason at ConsejoSano’s North Hollywood office in Los Angeles, California to discuss the complexities of the US healthcare system.
CJLPP: Much of your work focuses on how to effectively include different cultures into the US healthcare system. Why is the healthcare system complex? In which ways is the US healthcare system not multicultural?
Abner Mason: At ConsejoSano, which means “healthy advice” in Spanish, we are focused on patient engagement and patient navigation. The US spends more than any other country on healthcare, even if you take it on a per capita basis. Yet, the results are not very good, in fact they are poor. We get results that are inferior to many of our counterparts who spend much less. And, the amount we are spending on healthcare is so big that it threatens to crowd out other priorities. States just don’t necessarily have these funds at the state level. We cannot continue on the trajectory we are on. We have to figure out how to get more for every dollar we spend on healthcare, because healthcare is one of the biggest budget drivers at the state and federal levels. That is a big huge problem we have to deal with.
At the same time, we have got a healthcare system that is not delivering great results. One of the reasons is that America has changed over the past twenty years. We are becoming a majority-minority country. California is already a majority-minority state. California is 40 percent Hispanic and if you add the other minority groups it is a majority-minority state. Texas has crossed over that threshold as well. According to the latest US Census, they project that we will cross over as a nation by 2050. So, we have this demographic change that has already happened, but our health system has not changed at all. It is still fundamentally an English-speaking health system. Additionally, health in the US has become more complicated. Our health system is the most complicated health system in the world. If you are part of that growing population in the US for whom English is not your first language, and you come from a different culture, you will really struggle to navigate the system. For people whose first language is not English and don’t really understand healthcare, they simply nod at 60 percent of what the doctor says, which means they often leave clueless. They leave without really understanding. That is if you can get them to go at all. My question is––would you go to see a doctor that could not talk to you? Would you be excited about going to the doctor if you knew when you got there that you wouldn’t understand half of what they were saying? You would be quite scared. You certainly would not be enthusiastic about going. All of these are reasons why we need to be doing a better job of bridging the gap between what is becoming the majority of Americans and the US health system.
The good news is that we now have tools available to us, and if we choose to use them and we are willing to accept that everyone is important regardless of background, culture, or language. If we are willing to say to ourselves and to them: we do not expect you to change in order for us to talk to you. We are willing to make a change in order to talk to you. The healthcare system has to meet people where they are and connect with them for who they are and build trusted relationships with them. People will engage in those efforts much more if they have a trusted relationship with their healthcare providers and the healthcare system. When that happens, it actually saves money. When people engage and get preventive care, it actually not only improves their health but it lowers the cost of healthcare.
There is one other big issue that is hanging out there. There is a lot of recent research that clearly demonstrates that if you look carefully at people’s health 25 percent is genetics, another 25 percent is dependent on the quality of the healthcare you get, and the rest is dependent on other social determinants. What I mean by social determinants is transportation, childcare, or any number of issues that are preventing access to healthcare even when it is available. That is why we end up with a healthcare system that is not delivering for a lot of people even though we are spending a lot of money.
CJLPP: Could you please speak to the complexity of acquiring healthcare coverage? What is the general populations knowledge of the many channels different populations must navigate to access healthcare?
Mr. Mason: Healthcare is complicated in the US. There is a good chunk of the public that gets their healthcare through their employer. We are the only country in the world that does this. Then we have this group of people who don’t get it through their employer but they work and they make too much money to get it through Medicaid. The Affordable Care Act (ACA) was created to close this gap. So most Americans don’t realize that there are these buckets, people who get it through their employer, people who don’t get it through their employer and get it through the exchanges with a subsidy if they need it. And then there are people who get Medicaid. And finally then there is a fourth group that people don’t talk about, which is the undocumented. Depending on whose number you believe there are twelve to fifteen million undocumented people in the US. They can’t get it through their employer because they are undocumented, and they cannot get it through the exchanges because the law does not allow it. They can’t qualify for Medicaid because they are not citizens. California, for instance, will cover some pregnant moms and some children even if they are not documented but that is only one state and not many states offer this and the undocumented people cannot afford to buy it on their own. So, you have that group at the very bottom that has nothing. There is really no option for these people other than to go to federally documented health centers and get care. So, they typically only go in when they are sick because they are not insured.
A lot of the people who fit into the “employed” bucket are complaining now because healthcare is going up so much. What used to be the case was that the employers paid for it, and they said, “We will keep your premium low and your deductible low.” What has happened now, in order to try to drive consumers to think more about how they try to manage their health care, the employers are moving to what they call “high deductible” plans, which means that you have to pay much out of pocket before the plan kicks in. Some people, from a policy perspective, think it is wise to actually force consumers to think more about how they spend their healthcare dollar. I think that for moderate-income families it is just not doable. I mean, what low-income family has five grand to pay out of their pocket if their kid gets sick? Or they get in a car accident?
CJLPP: You recently founded a company called ConsejoSano, which uses technology to make healthcare systems more accessible for people of diverse backgrounds. What role do you see technology playing in healthcare access for underserved populations?
Mason: Technology is the way that we are going to deliver quality care for everyone. There is an opportunity, if we do it right, to deliver it in a more cost effective way. The classic example is telemedicine––being able to talk to a doctor by phone. It has the potential to really drive down costs and to save money and to give people immediate access to high quality care. Healthcare is different than other parts of the economy. In other parts of the economy when something new comes along and it is useful, there is usually a pretty quick uptake. Healthcare is different because it is so highly regulated. It involves life and death. The healthcare industry is very structured; there are legacy players who don’t allow for things to change very easily. Telemedicine is a good example because it is new, and it really takes advantage of the mobile phone that you can use anywhere. But most Americans today are not accustomed to talking to their doctor on the phone. In their minds, they have this idea of going in to see a doctor who really spends time with them. So telemedicine, even though it has the potential to be a huge cost saver, a huge extender of care to people, has had a very slow uptake. That is a result of, one, people are not used to it and, two, the regulations have prevented it from growing as quickly as it could. For example, doctors are not licensed by the federal government, doctors are licensed in each state. So. in order to practice medicine in any state in the union, you have to be licensed in that state. What that means is that it is not where you are licensed that is important but where the patient is. That is the point of telemedicine––to connect people by phone with a doctor who is available and is best able to treat them. But if they are physically in Texas and that doctor is in Florida they can’t. If you are going to be a national telemedicine provider and want to serve patients anywhere, you have to have doctors licensed in every state.
Another area in telemedicine that really causes a problem is HIPAA, the law that is designed to protect patient privacy. When that law was designed, at least twenty years ago or more, the intent was good, it was to protect people’s privacy around health information. But we live in a different world now, and people want access to their electronic health record, and they want to be able to share it more easily either with other care providers or family members. The constraints around HIPAA make it really difficult for some of the newer technologies to really blossom––we need to update some of the regulations. That is another example of how some of the regulations in healthcare can create a barrier to the successful implementation of technology. I’m not saying throw out all the regulations, but regulations need to be updated. Now that everyone has a mobile phone we need to allow people to have access to their own EHR (electronic health record). Those are examples of changes to have if we are really going to see technology take off in healthcare
CJLPP: Has your switch to working for a venture-backed digital health company changed the way you see government involvement in healthcare?
Mason: There is no question. When you make that switch from government to the private sector, you have a very different perspective. An example is when you are in government, and you are excited about doing something new and want to put together an RFP (request for proposal) to offer a new service. In the many years I spent in government, it never dawned on me that it was odd that the RFP process could take six months and usually much longer from beginning to end. So the idea of working with government for a lot of companies––especially small companies––where you are not getting paid for six, nine, twelve months, a small company can’t do that. A small company would go under. Our government––state and federal––is currently not set up to work with smaller companies. That would not be important to the average taxpayer if it weren’t for the fact that most innovation comes from small companies. So the government is in effect, by the way it contracts, closing itself off to the best, newest, most innovative ideas, and that is something that taxpayers suffer from. Government is slow and I’m not saying that it can be as fast as the private sector, but it could be a lot faster than it is. As we try to develop a more innovative economy and try to bring innovation into healthcare we have to figure out ways to speed that process up. We have got to do better.
CJLPP: Healthcare outcomes for citizens have not been improving as the percent of our GDP spent towards healthcare increases. What does an effective public health policy entail for establishing a comprehensive, value-based healthcare plan?
Mason: In all humility, I don’t think anyone has the answer to that. I think we need to try more things and see what works. We need to bring, in a compassionate way, a more market-based approach to healthcare. In other aspects of life, the costs of things go down naturally. When a new technology comes out, even though they are improving the capabilities of that product, the cost actually goes down based on any kind of standard measure. In every other part of the economy, prices go down even though the capability and the functionality goes up. In healthcare this hasn’t happened yet. One reason why that is the case is that in every other area of the economy there is more price transparency. People know what they are buying and they can compare prices. I think that is one of the reasons why healthcare in the US is not seeing the improvements that other aspects of the economy has. I recognize some people will take a totally different approach, they say that we don’t need to move to market solutions. I respect that but I think it could be that those same market forces would have the same effect on healthcare that they have on every other part of the economy. It is always the case that when market forces start to take a role, people make decisions based on their best interest.
I did make a caveat though: with compassion. We don’t want to say that market forces are the only thing. For instance, if someone doesn’t have any money in our society today, we would just say you couldn’t buy a laptop. That’s the market at work. We don’t want to do that in healthcare. Someone needs a knee replacement or they need a heart. We don’t want to have the market forces applied in healthcare exactly the way they are in the rest of the economy. In healthcare, you can’t say that you can’t have healthcare when you don’t have any money. So, I’m not saying that market forces should be exactly the same as they are in other parts but if we could have some compassion and find some way to inject market forces that would go a long way towards solving a lot of the problems we have in healthcare.
In all fairness, there are some people who believe just the opposite. They look at the same problems and they say that the answer is not more market forces, not at all. In single-payer systems, like in other countries, no one worries what healthcare costs at the individual level because the government pays for everybody; healthcare is a right. And you don’t have to worry about what it costs. I think that approach has some real problems with it, but I respect their opinion. I am just fearful that the single-payer type of approach doesn’t work very well in most places because you end up with a two-tiered system anyway. Take Canada for example, where there is a two-tiered system. There, if you have money then you get care better and faster. In my opinion, inserting more market forces in a compassionate way would bring down market forces like that. You do need to do it in a way such that there is a minimum below which no one falls. That is what I mean by compassionate.
CJLPP: Would you mind elaborating on the single-payer versus the US healthcare system?
Mason: Many countries have adopted a single-payer system. I would challenge two things. Firstly, it doesn’t work as well; in every instance it becomes a tiered system. Basically, everyone who doesn’t have a lot of money ends up depending on the government system and the people who have money get around it by having private insurance and private hospitals. And the good providers want to practice where people are paying more. Not only is it a two-tiered or three-tiered system based on money, but the quality of care then also shifts. This is because in public systems, the providers don’t make as much as they do in the private markets in those systems. So, the best care, the best equipment always goes to those with money. If there is a new device that can save your life, maybe there is a new technology or procedure. It is probably expensive for the government to get––it could be three to four years before it is in a government facility. In a private facility, you can have it in six months. If you are a patient, you want to be at the private clinic. Because it could be the difference between you and someone you love living a long life or not. But at the government level, by waiting five years, the cost of that piece of equipment probably goes down. So from a cost perspective at the aggregate you have actually saved money.
These aren’t easy decisions. I’m not saying they are easy. But for people who push for single-payer without recognizing the challenges that exist even where it is been implemented, I think they need to take a closer look. People like me, who believe that more market forces could work, have to put more thought into how we think it could be done in a more compassionate way. I believe we have got to have a threshold below which, regardless of their legal status, we don’t let anybody fall. But, I respect people who feel differently and say that they want to go single-payer and get rid of the middlemen, the insurance companies. But, the truth is that the government would turn around and contract it out, so there would still be middlemen they would just be called something different.
The other thing worth mentioning is that sometimes where you start off can constrain where you end up. For the individual, you should never let where you start off constrain where you can go no matter where you are born or what you are born with. But for societies, because of the historical way that societies develop, where you start off can sometimes constrain where you can go. Because we have an economy where people believe in more free market-based systems it is a heavy lift to go from where we are to a single-payer. It is hard for the vast majority of Americans to wrap their head around it because of who we see ourselves as and how the market defines who we are. I do have a concern that it is culturally just too hard for our country to make that step. Sometimes you have to choose another path. Maybe the more practical thing is––instead of hitting your head against a wall––is to take a little different approach that might achieve similar goals but is more consistent with how we view ourselves as a country. We don’t like change. We even have this love-hate relationship with the government. If you say to people that the government is going to take over healthcare they will be up in arms. But, if you say, “Do you like your Medicare?” The same people will “Yes, don’t mess with my Medicare.” If you travel around the world, there are countries that see a bigger role for government and they are comfortable with that because of the way the country has developed culturally. They are okay with it. But Americans––we don’t like that. It is hard to take big steps, to have the government “take over”.
What I just described could change over time, as more young people become the majority. I haven’t seen recent polling, but if you ask younger people I bet that a single-payer system is more popular amongst college students than it is with fifty to sixty-year-olds. In some sense, time may solve some of these things. It could be that in another 10 or 20 years, enough young people will have grown up with a different view of government, perhaps a more nuanced view, and could usher in a single-payer system.
CJLPP: Thank you very much for taking this time to meet.