The Doctors’ Lounge
Where scalpels meet systems — and physicians say what they really think.
Co-hosted by Anish Koka, MD & Anthony DiGiorgio, DO. Candid talks on healthcare policy, reform, physician autonomy & patient care.
The Doctors’ Lounge
900 Regulatory Hurdles: Why AI Isn't Replacing Doctors Yet
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Episode Summary
With scheduled guest Dr. Geoff Manley pulled away by a medical emergency, hosts Anish Koka and Anthony DiGiorgio turn the episode into a news roundtable. They open on a JAMA op-ed by Neil Khosla and Ezekiel Emanuel arguing AI will replace physicians outright, and push back on both the regulatory timeline and the incentive structure behind it — including why hospitals are slow to adopt AI tools that already exist, like AI scribes and pre-charting. From there they dig into Medicaid: Michigan's $350 million in new staffing costs tied to One Big Beautiful Bill work requirements, the distortions created by the 90% FMAP for expansion populations, Medicaid fraud recovery data, and Anthony's "food stamps for healthcare" pitch for a cash-equivalent alternative. They close by dismantling the widely cited claim that Medicare for All would save 155,000 lives a year, walking through the underlying studies and what randomized data actually shows about insurance and mortality.
Chapter Markers
00:16 Introduction and the JAMA op-ed on AI replacing physicians
07:04 Regulatory hurdles to replacing physicians with AI, and billing codes for AI-assisted care
10:08 Why hospitals aren't adopting AI tools that already exist — scribes and pre-charting
17:01 Healthcare's unlimited demand at zero price
18:53 Michigan Medicaid's $350 million work-requirement staffing costs
22:09 How administratively complex Medicare really is
27:27 Medicaid expansion, the 90% FMAP, and state incentives
31:51 The case for "food stamps for healthcare" — a cash-equivalent Medicaid alternative
37:05 Medicaid fraud control units and state-level innovation
40:41 Debunking the 155,000-lives Medicare for All claim
52:21 Medicare for All and the future of private practice
55:34 Wrap-up and next week's guest preview
Co-Host Handles
@anish_koka and @drdigiorgio
Show Handle
@drsloungepod
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SPEAKER_01Welcome everyone. Back to our Thursday usual day. Next week, we're back to Tuesday, so uh we'll have to try to update people today. Today we uh have a good guest who's hopefully coming, still in the operating room, apparently. But uh while we're waiting, I thought we'd there's so much going on. I thought we would get to Only a few things. Only a few things. Man, I I can't even begin to know where to start. I like I'm already forgetting everything. So, first, we have the op-ed in uh JAMA of how AI will replace doctors. It's by Neil Kosla and Ezekiel Emmanuel. Neil Kosla is the son of Vinod Kosla, who's a prominent venture capitalist in Silicon Valley, who started or was a founder or something in Sun Microsystems way back when, and since then has done Kostla Ventures and is one of the prominent VC firms there. Um, his son is also, I guess, in the space and has a has a healthcare startup that's uh dedicated to uh proving that uh AI is better than human doctors. And voila, there's a JAMA op-ed written by Kostla et al. that says yes, AI is going to replace doctors, and it's not AI plus doctors, as everyone was kind of thinking about, because doctors adding to AI is going to make the whole thing worse. So therefore, he's proposed AI will replace doctors. And then after that article was published in JAMA, the North Kosla, who has a prominent Twitter account, posted on it, posted on this paper and then tagged CMS saying we must act. CMS must act. Dr. DeGiorgio, your thoughts on the waning days of the physician?
SPEAKER_02Yeah, I'm glad I have alternate career paths open to me, like interpretive dance. I think my assisted physicians are here and I think it's wonderful. I use AI. I have no problem looking up stuff on open evidence, even with the patient in the room. But I think it'll be a little while before it replaces surgeons. Certainly those of us that do the technical work, the surgeons. But my point to it was I mean, because they gave a very aggressive timeline, five to ten years before AI will replace us all. And of course, my point was that there's about 900 regulatory hurdles, just even if the technology was there. And if anyone knows how uh the pace at which we go in regulation knows that that's not going to happen anytime soon. Our guest is giving me a call, so I will let you monologue further.
SPEAKER_01Oh, yeah, absolutely, absolutely. So no, I think it's obviously Dr. Georgia Anthony brought up a great point about uh the fact that there's a ton of regulatory hurdles. But beyond the regulatory hurdles, well, one, I think it's a little inappropriate to get this imprimatur of the JAMA brand to say that, ah, look, we have achieved something great. We have AI has gotten to a point that we are published in JAMA, which is kind of the thrust of what the KOSLAS were saying, which just kind of gives it leaves a very bad taste. What are we going to do? Have the CEO of Moderna talk about how terrible conventional vaccine platforms are next and have that be in a JAMA perspective? Yeah, I think I think it's stuck in a lot of the cross of uh the doctors around um I mean, this is not the way that normally evidence kind of unfolds, right? You normally have some new thing and you're you have to check it against what exists and see if it's better, try to figure out how much better it is. And you certainly, this whole business of tagging CMS to ostensibly generate a billing code. I mean, this is how like many current on-the-market zombie therapies are worth billions and billions of dollars because you have a billing code and Medicare will pay for it. And that that's just this game, this arbitrage that too way too many people kind of are getting extremely rich. And it's all off of US taxpayers. And oh, by the way, did I mention that we are extremely broke and every and we're just printing dollars at this point. So yeah, so I think that was I so yeah, but but speaking to the actual matter of will AI replace physicians, is AI better than is AI going to be better than physicians? I mean, I think if you look at something that's much, much simpler than what should happen, ideally you have a comp, you know, a complex or simple case that comes to the fore and you have a clinician that examines everything and then is arrives at a diagnosis and makes the appropriate treatment. That is a cognitively a more complex thing than say driving, right? I mean, I think we have folks with IQs of 70 or 80 that probably drive. I think that's probably right, or something, whatever, less than 100. So something that's not high cognitive skill, and we still aren't in a world where we have unsupervised full self-driving, right? Uh we have FSD with Tesla, I guess they're the leaders, but that's still very much supervised. And in large part, that's supervised, not just because of regulation, Anthony's point. It's partly supervised because there are edge cases that are catastrophic that will kill person kill you if you're not paying attention. And that has happened. Yes, on average, FSD is safer than humans because it's all seeing and it never takes a break in terms of paying attention.
SPEAKER_02But yeah, I mean Waymo has a human connected at all times.
SPEAKER_01Yeah, Waymo, right, right. FSD does not, and FSD doesn't have, I'm sorry, Tesla does not, Tesla doesn't have LIDAR or whatever it is Waymo has. I don't know if Waymo still has LIDAR or whatnot. But point being is that you know, you're so worried about edge cases when you're talking about autonomous self-driving, which is much, much simpler than being a clinician, that you want a human involved, even a human with an ADIQ involved, because uh even a human of with an ADIQ apparently can figure out what is and is not a catastrophic thing if they're paying attention. So yeah, I do I think it's a little premature to talk about uh something that's much, much more cognitively demanding if you're trying to do it well, to be replaced, replaced humans completely? Yeah. So and I don't understand what the purpose of it is in terms of making that leap. You have to somehow, in order to make that leap, you have to believe and you have to create a framework that says that human plus AI makes the AI worse. And what's the reason for that? The only reason for that is if you have a company which stands to say, yes, AI will replace humans. So I look, I think the whole thing is it comes off somewhat as con man styled stuff. Look, make your product, sell your product to the public. I mean, there are Tesla is not something that's subsidized by the US government. People are going to use it if it's highly if they if they find value from it. Uh, there may not be objective value things. I mean, as Dr. Dr. DeGiorgio's famous healing crystals, they're $10 billion or whatever it is, industry. Let people let people buy it. But we 100% should not be subsidizing this through the U.S. taxpayer. Like, no way, should in no way, shape, or form should we do that. That is a gigantic, gigantic mistake.
SPEAKER_02Right.
SPEAKER_01So that's my yeah, go ahead.
SPEAKER_02Yeah, I was just gonna say just an update if anyone clicked on the link expecting Dr. Jeff Malin to talk traumatic brain injury. We are not today. He's uh he's dealing with uh unfortunately uh a medical emergency, which is the downside of having doctors on the show. We are notoriously fickle when lives need to be saved. So that's it, but we will reschedule him. So Anisha and I are going to talk healthcare news. The problem with a healthcare news podcast is there's just so little to talk about, right? And the issue, there's nothing ever happens. So back to AI. My real interest is, of course, in the regulatory area, and how are we going to first of all rewrite the hundreds, if not thousands, of federal and state statutes that uh indicate physician as an individual for many of these things. Everything from billing Medicare to signing a birth certificate to sports clearances to prescribing medications, DEA controlled substances, all of these statutes mention individual physicians. Um and so everything would need to be changed in both federal and statewide uh in order to replace physicians with autonomous AI. Can that be done? Sure. But again, as I was saying earlier, the pace of regulation is gonna make that extremely slow. Really interesting thoughts on how to bill AI in Medicare. So can AI itself as an autonomous machine bill Medicare the same as a physician can? I don't think we'll reach that stage. I think it's gonna have its own separate thing. But there's also a lot of talk about CPT coding for AI assisted services, right? So if you as a doctor, maybe to incentivize doctors to use AI, CPT could come up with codes to like an add-on code or a separate code. So if you and but you use an AI to help with your clinic visit, you could use a modifier or a separate code for the use of AI. Um, I think that's certainly a way to incentivize AI uptake, but at the same time, it seems odd to create a billing code to pay more for something that should be making you more efficient, right? It'd be like giving you a modifier to use a calculator to do math instead of doing it by hand. So I think that's it's a little bit backwards and it goes against what CPT and the RVU calculations that go into the codes because the more efficient you are, you're actually supposed to get paid less, at least have fewer RVs.
SPEAKER_01I am and this is gonna fall in deaf ears because physicians in large part seem to have deaf ears and seem to just do what is best in the short term. It's really frustrating. It's like the it's so obvious, it's these carrots and you know that turn into sticks. I mean, yeah. 150%, there's gonna be a bajillion dollars to be made by a bunch of AI scribe companies and whatnot. Literally, you know, these folks are working, they don't work weekends, they're not taking calls, they don't have liability on all that stuff, and they are begging for a billing code to add on, and physicians will get some peanuts or whatever of it, and you know, physicians go, oh yeah, we're gonna increase our revenue by 10% if we get this extra billing code. But in X number of years, because the AI is making you more efficient, they are going to cut the cut your reimbursement. And it is going to happen.
SPEAKER_02And part B is budget neutral, right? And so if there are more RVUs out there, if everyone cannot make 10% more because it all has to end up being budget neutral in the wash.
SPEAKER_01Yeah, yeah, exactly. Exactly. Please, please, it is not something that, I mean, if it provides that much value to you that you're gonna be able to see X number of more patients, go ahead, pay, pay, pay for it as a practice, pay for it as a hospital, pay, do whatever. Do not come up with some billing code for it in large part, because yes, it's budget neutral that's gonna turn into something that's bad for physicians, but the other part of it is that you're just gonna keep zombie companies alive that do an okay or so-so job that have a great sales team.
SPEAKER_02So yeah, I think let me ask a question then. So there are AI tools that can make our jobs exponentially easier that exist right now. And for the most part, large hospital systems are not taking those up. The example I've I've given many times is there's many hospital systems that will pay advanced practice providers, which are nurse practitioners and physician assistants, a normal salary. And these individuals tend to make two to three or even four hundred thousand dollars a year. Um so they will pay them to do what's called pre-charting, where they go in before the clinic, before the doctor sees patients in clinic, and they will just gather all the information and summarize it in an easily digestible way for the physician before they see the patient. That is something where the AI technology exists right now to do that probably better and more efficiently and certainly cheaper than hiring these advanced practice providers who don't want to really be doing this either. They would much rather have their own clinics and be seeing patients, right? So nobody is benefiting from these. These advanced practice providers could be doing other things, yet we're paying them to do something that a very, very cheap, if not free AI tool could do. So why are hospitals not doing this? Why are they so stuck in their role? Is it because they're sclerotic? I know we talked about this with Dan Donahoe a few weeks ago. But why, Anish, do they not feel the pressure to adopt these tools earlier?
SPEAKER_01Yeah, I s struggle to understand why but I mean why are hospital systems so in general inefficient? I mean, I I don't know if it's the easy thing to choose, easy choice to choose, but it feels like there's just a large level of inefficience and incompetence, and unless some I don't know, unless some Mackenzie consultant says it, and maybe that cycle takes like two or three years for McKenzie to recommend it. Like I went into this new hospital building and it's like it's like a spaceship. It's amazing. There's like there's like three giant TV screens every four cent every four feet, and uh there aren't receptionists have been eliminated. I mean, so they do do things and move in some direction when it suits them. They just don't seem to be very, very nimble in terms of on the adoption standpoint. Like why is it that well yeah, why is it that we didn't introduce tele tele for you know or Zoom for our conferences? Why did we always have it to be online? And it took COVID and the pandemic to be like, oh, I guess people can log in remotely. Right.
SPEAKER_02Well, for for appointments, uh for patient appointments, that was again largely regulatory driven, right? There were rules prior to 2020, there were rules about telehealth that made absolutely no sense. So the patient had to be in a healthcare facility to be on the other end of a telehealth call. So a patient had to go to a doctor's office to be on telehealth, which made absolutely no sense. So of course nobody's gonna adopt it. Plus, it paid less than an in-person visit. So if the physician's office still had to pay for the MA, pay for the facilities, then why not just have make the patient come in because you're gonna get paid less if you do it over telehealth. Uh so regulator regulations were what prevented telehealth from taking off. They adjusted all that for the COVID pandemic, and sure enough, telehealth took off.
SPEAKER_00Right. Right.
SPEAKER_01Yeah. So this telehealth then you have this telehealth billing scheme that arises and uh Yeah, I wish I wish we weren't so dependent on it's just the model. The model is fee for service, and now we're so dependent on a billing code uh arising to do something that's efficient. So But yeah, why don't, for instance, why doesn't every primary care physician who works for a large health system have a scribe? I mean, a scribe is what, fifteen dollars, twenty dollars an hour, right?
SPEAKER_02How many extra patients probably twenty dollars an hour, yeah.
SPEAKER_01Yeah, how many extra patients do you need to see does a primary care doctor need to see so that you can make up for that scribe, right? But no, I mean that doesn't happen ever, right? You just have this weird system where things aren't really optimized for physicians.
SPEAKER_02The other point I made with AI today is that they we have these AI scribes, they're fantastic. I love my AI scribe, it and I don't like it because it saves me time. It really doesn't, but what it does is it it catches more detail. So if I'm trying to simultaneously talk to the patient and type and listen, I miss things, I miss some detail. And so the AI scribe catches more detail um that I would otherwise miss, and I really appreciate that fact. Um, however, it doesn't really save my time because I still have to go through the note and edit it and look at it. But the AI scribe, while I'm talking to the patient, will, with complete validity, take down the diagnosis, take down the plan, and accurately do all that, and it will track how much time I spent with the patient. So it does everything necessary for the physician orders, for the diagnosis code, and for the billing code. However, after that, doctors still have to go in and click through the electronic health record to manually enter the billing code, the diagnosis code, and all the orders. So it's an extra 200 clicks approximately to close an encounter after the AI scribe has already, with high fidelity, transcribed everything that needs to go in there. So why can you not get to the point where the AI scribe can just take everything the doctor says, enter that into the computer, probably with better fidelity than making the doctor click it and get rid of those 200 clicks? You could easily squeeze another few visits out of every doctor or at least reduce the fact that they're doing all this charting late at night, reduce the burnout, make it more appealing for doctors to work. So again, why are hospitals not doing this? I mean, the technology is there. Is this not otherworldly? It's been there for years to do this at pretty high fidelity.
SPEAKER_01Yeah. It's because physicians don't own and things are not optimized for the physician, you know. So they don't they don't care. It's just oh, just another click, just a couple other clicks for you to do. Oh, we can't take a verbal order. We have to you have to get up and put it put that order to hold the Tylenol in because that's what's safe. I mean, again, none of this would happen in a physician-owned environment. It's just extremely frustrating. So, yeah, if you want things to get continue to get more and more expensive, yeah, let's keep adding technology to this ridiculous morass of things that we have where physicians who should be the folks controlling the patient experience and that entire flow of patients as they touch healthcare. Yeah, physicians should really be the ones because we're the advocates. We're the advocates for patients. No, I mean, there's reasons that you care about an on-time start that have to do with when it is you end and get back to your family, but but guess what? I mean, patients don't want to be waiting around waiting for their surgeries to start. So no one is as aligned for physicians as for patients as their physician, because we want our physicians, geez, we want our patients uh to do extremely well. We and unfortunately, we are generally in health systems emasculated. You have to wield a tremendous amount of power to really get anything, to really get even minor, minor things done. And they're every step, there's some administrative units, some of whom are physicians that are sitting there to uh waiting to block you. So really frustrating. But yeah, no, so yes, you are so speaking you speak as a man beaten down as you talk about when people come in and we're like, oh yeah, yeah, I'll replace doctors, it'll be fine. It's like okay. There's a couple hurdles there that are regulatory even before you get to all the other places.
SPEAKER_02Whoever wants to take call at night, by all means, let me sleep. Yeah. So this uh brings you up to another conversation I had, and this was uh spawned off a conference I was fortunate enough to speak at looking at Medicare reforms. Um and then I I tweeted this out because I was spurred on, but it was just one sentence is that healthcare has unlimited demand at zero price. And if you look at other commodities, things like food and housing at truly zero price have essentially unlimited demand, right? Everyone would love a really nice house on the beach that's really big if price was zero. And I got some pushback a lot from our our friend Dr. Gaffney, but what are your thoughts? Does healthcare truly have unlimited demand at zero dollars, Anish?
SPEAKER_01I mean, yeah yeah. I mean healthcare has yeah. Well, I mean the data they forget about my feelings on the matter. I mean, the the data suggests that is absolutely the case. I mean, when you increase the cost to patients, utilization falls, right? So yeah, if you if you take cost to patient to zero, demand goes up a lot. So uh yeah, I think that's one of the laws of you know, certainly, you know, I think there's economically that is something that is relatively predictable. But it's also happened. We've seen it. We've seen what happens when you have large subsidies towards certain things. You end up using a lot of it.
SPEAKER_02Right. And I my hypothetical was, and I think we're getting there, if you have a doctor in your pocket that has access to all your healthcare information and you can quickly pull it out and consult it anytime you have a health question, what would the utilization of that be? And it's it's pretty darn high. It's certainly a higher than the capacity of any human physician workforce could ever meet. Right. And I think if we recognize that fact that healthcare has unlimited demand, and if you truly make it zero dollar cost to the patient, there is no amount of healthcare capacity that will meet that demand without some sort of rationing. And if you're gonna make the price zero by a governmental fiat, then the government's gonna have to ration it when the demand goes through the roof.
SPEAKER_01Yeah. No, absolutely. What do you make of uh the uh notion that so there's this news item that came out? Michigan's Medicaid program is uh spending $350 million on new staffing to deal with the one big beautiful bill red tape.
SPEAKER_02I love it. So if you look at that, the $300 something billion that they're spent, a million billion, what is it? Yeah, $350 million. It's all made-up money anyway. It's all made up money. So the $350 million, a substantial portion of that is going towards people providing job assistance. And that is the point of the work requirements. The point of the work requirements was not to punish people and kick them off Medicaid. The point of the work requirements was to incentivize them to work. Because in expansion states, it's important to realize how the Medicaid work requirements in the one big beautiful bill were constructed. But in expansion states, so we're not talking about the original Medicaid population, we're talking about young, working, able-bodied, working poor. In those patients, if they are not working, then they will not get their coverage. So the the work requirements were to incentivize this patient population to get back to work. It does not apply to disabled, it does not apply to pregnant women, it does not apply it apply to children, obviously, and it does not apply to the elder, anyone over 65. It is only the expansion population to get them back to work. Because as any doctor knows, if your patient is working, they're going to have much better health outcomes. And so the with the one big beautiful bill, in order to implement it, many of the states, because they want to keep these patients enrolled in Medicaid, because 90% of are reimbursed by the federal government, the states have every incentive to keep these people on the program. And therefore, they are providing work assistance for them. I think that is a fantastic investment for the states. The city of San Francisco now has a jobs assistance program specifically aimed at keeping people in the workforce so they can maintain their benefits. This is exactly what the bill was supposed to do. It is incentivizing local areas to invest in job assistance programs and get people into the workforce. And the the work requirement is actually pretty minimal, just 20 hours a week of either education, work, or community service. So they could go pick up trash for the city and they could go clean the parks, they could do anything that that meets those requirements and and satisfy it. Right.
SPEAKER_01So you're saying that $350 million is not bureaucratic bloat. I don't think it is.
SPEAKER_02Some of it, sure. Uh they have to do instead of checking every year to see if patients are eligible, they have to check every six months. So that's obviously going to take a little more administration. They're going to have to have some sort of mechanism to make sure that disabled people are not kicked off of Medicaid due to the work requirement. So that will take a little administration. But again, these are good things. There is a lot of bloat in the Medicaid program, and having a little bit more administration to reduce that bloat is a good thing, especially because the states control the program, but for the expansion population, the government reimburses 90%. So that's like me telling my kid, I'm going to pay for 90% of whatever the heck they want. Right? They're not going to have very much motivation to curb their spending. So I think it it's important that the states have a little bit more incentive to look over their Medicaid program and make sure they're spending the money appropriately.
SPEAKER_01It is interesting. That spending money on administration, you made this point. Spending money on administration is only a problem in certain contexts. Why is that, Anthony? I mean, I think apparently Medicare does require no administrative. Medicare, Medicare for All would be no administering at all. No administrative. I mean, that is the history of Medicare, where over time Medicare has not increased in bureaucratic complexity or administrative complexity. So I'm joking, folks. I mean, the administrative complexity of Medicare since 1965 is absolutely insane. All right. So and literally the program is going bankrupt because it they needed help administering the benefit. They turned to the private companies to say, hey, please, insurance companies, help us administer this thing. And I mean part that's because traditional Medicare can't say no to anything. And now you have this other program where suddenly you can be a Medicare enrollee and say no to things. So yes, that's in part related to that. But okay, that that that does suggest that you need there is a level of administrative complexity that's needed to kind of manage Medicare. Would there is there a can you envision a system which would require a lot less administration than the current morass that we have?
SPEAKER_02Well, I think it to anyone who says that Medicare is has low administrative burden, look at just the physician fee schedule for uh 2027. The proposed rule for the 2027 physician fee schedule is over a thousand pages long. Right? So for the someone who would claim that that is simple is simply not reading. I mean, what Medicare does is it offloads the administration to other entities and then says as a proportion of claims billed that their administrative costs are low. That has two problems. One is that they offload a lot of the administration to uh the IRS to collect a lot of the payments for it. They offload administration to doctors and hospitals because we're the ones that spend all the time reading the CPT manuals, taking the coding courses, hiring billers and coders, hiring people to clean the data for their numerous quality metrics. If you look at the data on how much doctors spend on billing coding quality metrics documentation and how much hospitals spend, it's astronomical. Those numbers don't get caught up in the numbers about administrative spend. And number three, if you're looking at it as a proportion of spending, the Medicare population is the most expensive population to pay to provide health care for. And therefore, because you're spending so much money on claims for actual medical services, of course the administrative spend is going to look low in proportion because Medicare beneficiaries cost a whole lot of money to provide healthcare for. So of course, if you're gonna, all things being equal, if you're spending the same amount of administration on a healthy 25-year-old or a sick 80-year-old, the amount you're spending and a proportion of total spend is going to be much lower on the 80-year-old because you're spending so much money on their health care. So Medicare does not have low administrative costs at all. I think that number is laughably false.
SPEAKER_01One of the interesting things about that, about that $350 million number is that uh it's a rainy day fund from the state of Michigan that is being pulled, that amount is being pulled from a rainy day fund to absorb the cost shock of the Big Beautiful Bill's effect on the state of Michigan. So one of the problems here is that the states are being are awash in federal funding for a variety of different reasons. And the Big Beautiful Bill, because the federal government is bankrupt, we're bringing revenue of like five trillion a year, and outlays are like seven trillion a year, three point five trillion a year of those outlays are Medicare, Medicaid, and Social Security. 900 billion or close to 1 trillion is defense. Okay, so for all those folks that are constantly crying about defense, you know, three and a half times spend on the social safety net compared to defense. All right. But one interest, like, for instance, take the SNAP program, right? The Snap program historically pays 100% of SNAP benefits. There is an error rate to SNAP benefits. And the big beautiful bill says, whoa, whoa, whoa, we have to, we're going to now make states responsible for a percentage of that actual benefit cost, not just pay that amount of money for SNAP benefits directly to the states, right? If you guys screw up, if you guys screw up, so the percentage the state the state owes is tied to that state's payment error rate. So Michigan's error rate is supposedly above 9%. And so that amounts to a significant chunk of change for what they would be on the on the hook for. So the sloppier your admin program is in terms of your error rate for the SNAP program, the more you're going to be on the hook for in terms of the actual benefit. It's a way to try to incentivize the states to be better about the benefits that they are giving out, especially the benefits they're giving out that are almost completely funded by the federal government. That makes complete sense. There's nothing wrong with that, right? I mean, the real tragedy here is that meaning, if you want to have a benefit, right, then you need to have some type of mechanism for fraud detection. Otherwise just have a much, much, much small smaller benefit, right? And then who really cares? But you know, what is the SNAP benefit in Michigan run to? Uh I don't know, I'll look it up real quick. But if you have if you want to have these large, really large programs, then yeah, there's going to be need to be some better administrating. And I think there's no better way to do it than to make states more responsible in one way or the other if they are not catching catching fraud.
SPEAKER_02So And that's again, that's the problem with Medicaid expansion. The more I think about it, I don't have as big of a problem with Medicaid expansion. I just don't like the way the Affordable Care Act implemented it, right? Your traditional Medicare, Medicaid, excuse me, beneficiary doesn't have 90% of their benefit paid for by the state. It has between six fifty and seventy-ish percent. Uh it's called what they use is called the F MAP. Whereas the poorer states have more of their uh Medicaid funds paid for by the federal government. Richer states like California have less of their Medicaid spent paid for by the federal government for traditional Medicaid enrollees. And that again is disabled, elderly, poor, pregnant women, poor children, poor families. When they expanded it to poor, working age, able-bodied individuals, they expanded it with the 90% FMAP. So every state that expanded it, the federal government would pay 90% of the costs instead of the traditional FMAP. And so that created a few distortions is one, it made it so the states got a big bucket of money for enrolling a lot of able-bodied folks into Medicaid. And by paying 90% of the costs, it made it really disincentivize states from being very cautious about their enrollment numbers. Because if they enroll people who are low utilizers of care, the state will get money from the federal government and 90% of that will be paid for by the feds. They'll only be on the hook for 10% of the cost. When they started using Medicaid managed care organizations, I'm generally a fan of MCOs. I like a private intermediary. But when they're using MCOs, they pay those MCOs a per member per month rate to cover Medicaid beneficiaries. If there's people that are in another state or have acquired private insurance or have died or who are otherwise low utilizers of actual Medicaid services, they're still getting money for those individuals, even if they're not spending any of it. So it really created a poor incentive for states to have really close administration of this program with the federal government paying so much of the of it. If they had just expanded Medicaid and kept it at the original F map, at the original matching rate, I think it would have it would have solved a lot of these problems.
SPEAKER_01Well then Medicaid wouldn't have expanded as much. You wouldn't have had as many people covered.
SPEAKER_02Right, exactly. Because states and it's this is what's tough, right? So I think anyone that complains about Medicaid not paying doctors enough, which is a legitimate complaint, really that's not the federal government. It's the states that decide what rate to pay doctors. So there a state could decide that they could pay the physicians the average commercial rate to cover Medicaid beneficiaries. The problem is that they don't, because that would require spending a lot of money. And so states don't have the money to do that. Um, but they certainly could. They could raise taxes, they could do a lot of different things, they could cut spending in other areas and maybe not pay for a high-speed train that's not going anywhere and instead use it to pay doctors average commercial rates for Medicaid beneficiaries so the doctors will have more appointments for them. But states choose not to do that. But if they wanted to, they could. And again, that's why it's a really complex topic. But the state directed payment program, some of the states were using those directed payments to get Medicaid payments up to average commercial rates, which there's plenty of evidence. If you do that, you actually create more access opportunities for Medicaid patients. So there's a lot of different ways you can fund Medicaid. And certainly I'm a fan of anything that can be used to get Medicaid payments up a little bit closer to average commercial so that those patients have access to care. But it it's just it's such a complicated system that the states have to do these tricks like the state directive payments and things, which just kind of look bad on paper.
SPEAKER_01Yeah. I mean, I worry from in terms of providing alternatives, like if you provide alternatives that end up with a high potential of being abused, you gotta be careful. So one so for instance, one of the things that we talk a lot about here is let's get the money to the people, let's get it into their hands. And we compare, you know, what what we say is a successful program, which is the SNAP program, right? The Snap program is here's an EBT card, go ahead and spend those dollars, right? And then you assume people are being somewhat more discriminating about what they're spending, right? But that I mean the SNAP program, the SNAP program is a huge program, right? The SNAP program is like, I don't know how many times this the size of the NIH budget, right? Just to go back to this Michigan Michigan example alone, just to highlight some of the issues with, say, having something like that. I mean, you're of course saying that you would still need some type of in your perfect world, would you say that is ideally some type of where you folks that are that fall under some level of income, you know, have a have a card, have an EBT card that they can spend on healthcare?
SPEAKER_02I mean, we gotta work on our branding, right? That's uh because Medicare for All fits on a bumper sticker. So my my bumper sticker pitch is food stamps for healthcare. Yeah, I think I got that from Josh Umber of Atlas MD, right? So I think if you if you gave low-income folks, instead of shuttling them into this Medicaid program that's highly inefficient and has all these perverse incentives, if you gave them a cash equivalent premium support subsidy, something they could use to buy private insurance or save as an HSA, I think it would be a lot more efficient and it would give those individuals, it would empower them to seek the same kind of care that you and I can get. Because if they have cash equivalents in their wallet, they can go to the same direct primary care doctor that we use or the same cash pay surgery center if they don't want to wait in line at the place that takes Medicaid. Just the exact same as people with SNAP can shop at Costco and Whole Foods.
SPEAKER_00Right. Right.
SPEAKER_01Yeah. So this the SNAP program, you know, in Michigan SNAP program is three billion dollars, covers a fair number of Michiganders who are below a certain income level. And interestingly, the administrative costs of that program is split between the federal government and the state 50-50. Then the benefits it itself is completely paid for by the by the state. Uh sorry, by the federal government.
SPEAKER_02Federal government. And it's about $100 billion a year, is what I just looked up for SNAP.
SPEAKER_01Yeah, $100 billion total all totally a year. Yeah. Which is which is again an NIH budget is $45 billion. So it's double the NIH budget. But Medicaid is a trillion. Medicaid is a trillion dollars. So this is this is this is cheaper comparison. Right. 10%. Well you're buying soda versus buying bariatric surgery.
SPEAKER_02But um, well uh well hold on. So I think the the median spend on food is is orders of magnitude higher than the median spend on healthcare, right? The median spend for individuals in America on healthcare is five hundred dollars a year, is the median spend. Right. So I think if you're looking at the median spend, most people spend more money on food on an annual basis than on healthcare.
SPEAKER_00Right.
SPEAKER_01Right. So the Medicaid numbers well, yeah, but I mean that's a guy, yeah. I guess it's a complicated question. I mean, Medicaid, of course, if you make health everything, you have a fat tail.
SPEAKER_02No nobody's eating a million dollars worth of food in a month, but some people will have a million dollar medical bill in a month.
SPEAKER_01Right, right, right, exactly. So uh humor me, Michigan, the uh amount, uh the national spend is $100 billion. Michigan's take on that is about $3 billion a year. Uh there's about $90 million in administrative costs, which is $50-50 for now shared between the state and the federal government. All three billion at the moment is covered by the uh of the actual benefit is covered by the feds. Now the error rate uh based on a random audit, random sample, and then extrapolating it out in Michigan for getting the benefit wrong, meaning giving the card to folks, I guess, who don't shouldn't have it, is around ten percent. So 10% of $300 billion is around $300, 10% of three billion is around $300 million. So uh they are basically saying that uh the amount that now would be footfall in the states would be the states would have to come up with $300 million because they have an error rate of around 10%. How does one is it so I guess that the mistake is not setting up something up front, not having an infrastructure to appropriately do this, right? Meaning if you cannot have a f you don't want to have a federal program that is all federal. You must have the pro program that is a shared program. Now you give up massive numbers that way because but in that's how you prevent ghost enrollment. And because now if the feds and the states both have an equal hand in what they're paying out, then you're gonna have a much tighter program being set up because otherwise it's gonna blow a hole in the state budget. As it stands now, it just blows a hole in the federal budget, so the states don't care. They're just like, whatever. Uncle Sam, it's Uncle Sam's problem to get money. So I think whatever program you set up, you really need a significant hand by the state. But the problem is if you do something like that, then the state may be like, well, it's not worth our time to like, why waste our time doing anything, enrolling anyone? So it's just an extremely uh thorny problem. So on one hand, you have this idea that if and so it gets back to your original question. If the if the cost of healthcare to the consumer is zero, like how much do we utilize healthcare? Well, we utilize a fair amount of healthcare if that happens. But if the cost is, if you increase the cost just a little bit, now suddenly, yeah, now suddenly you have a very, very different uh flavor. And I think we're not going to get anywhere until we more widely understand that because everyone isn't utilizing healthcare to some max degree isn't necessarily a bad thing. I mean, that's just the way the way is different people utilize healthcare to different different amounts, and we need to be okay, and different people value different things, right? Somebody will somebody will spend $500 on you name it, that isn't healthcare, that you and I would perceive as, well, why are you spending $500 on that when your BMI is 45 and you could get X number of months of a GLP one for the same amount, right? So you routinely people spend a lot of money on tobacco, on alcohol, on guns, maybe, but they're not spending anything on healthcare. And that's a value preference that that different segments of society are going to make. And part of the issue is that I think a large portion of the of the public thinks there's something wrong with that. And we must give them force healthcare down their throat or force some card that they have, and then we feel better if they have a card that says, I have I have healthcare.
SPEAKER_02And so it's I think it comes down to that the Milton Friedman point, right? It's it's a lot easier to spend other people's money on other people. And it the same works for the states. So if you're gonna say, here's a big bucket of money, spend it how you wish, and we'll just give you more money if you spend more money. That's essentially how Medicaid works, right? It's with this 90% recovery. So they had these things called Medicaid fraud control units that are supposed to root out fraud and overpayments. In see the 2025 numbers, the Medicare Medicaid fraud control units spent $400 million uh rooting out fraud. The federal government picked up $300 million of that tab, and they recovered $1.3 billion in fraud. So these are actually highly profitable government institutions, again, mostly paid for by the feds to recover a lot of this, a lot of this money. Actually, sorry, it was $2 billion. Uh the $1.3 billion was in criminal recoveries. They had $700 million in civil recoveries, and so they uh garnered about 4x return, 4.6x return on investment on fraud recovery. But there's huge variation in states. And in fact, the New York uh fraud recovery unit just got decertified by HHS last month because they did not actually go after much fraud. So it's it's one of these things where again the feds are like, hey, here's all this money, uh, and here's also some money for a fraud control unit. Please go uh be good stewards with our money. And there's not that incentive for it. So I I don't have a good answer. I think obviously I think the the libertarian-ish side of me wants the states to have more control over this. I certainly like that aspect of Medicaid, is that you have essentially 51 different programs with each state in DC, and you get these little experiments like Indiana, which is giving states the opportunity to have Medicaid beneficiaries take part of their benefit as a cash equivalent card that they can use for things like direct primary care. I believe Georgia is following them similarly. You have innovations in drug pricing like you got with Louisiana, where they essentially had a subscription, like a Netflix type program, is what they called it, for some of the more high-priced drugs. So you really have a lot of innovation on the ground with Medicaid. But again, the overall problem is the problem of incentives is that ultimately most of the states are spending a lot of federal dollars on programs they control. And so if they can offload a lot of the cost, uh you don't have the same incentives from the federal and state perspective. So I that's why I like Medicaid. I wish that the states had I wish the states could keep this leeway. One of the things I tell people in Medicaid policy is that if a state wants to run a poor, a poor Medicaid program and do silly things with their money, then they have that right. But what they don't have a right is to use a lot of federal funds for a poorly run program. So I wish that the states could just fund more of it on their own and and do what they want. And then we have a bunch of experiments on what's the right way to do health care for the poor.
SPEAKER_01Yeah. Yeah. And def defining that is kind of important. But yeah, and unfortunately, it gets caught up in the culture wars where anytime you talk about any type of Medicaid reform, it just becomes, okay, you're a right wing, this is some right-wing thing, you're going after Medicaid. But I mean, I don't think anyone should be against going back to the old system where we didn't have a 90-10 match. I mean, just something simple like that, right, is something that would really help to preserve a program that you want to be specifically targeted to folks that really need it. And then and then, of course, the that other aspect that we're bringing up about simplifying the program, have a give money into the hands of the of people so that they can spend the doll those dollars as opposed to third third party. I think that those kind of basic things are like are gonna be super, super important. All right. Medicare for all will save hundreds of thousands of lives per year.
SPEAKER_02Bazillion dollars according to Yale, right?
SPEAKER_01Yep, yep. It'll save billions of dollars and save lots of lives.
SPEAKER_02Per year. This was based on a this is not proof. It is a model that they projected. And in that projection, they admitted A, that there would be increased demand. They made no account for that. And B, that model assumes that all doctors and hospitals would be okay with taking Medicare rates. How would coca cardiology do with Medicare rates only?
SPEAKER_01Well, I mean, we would not as well. Medicare rates only. But Adam Gaffney and at all will say, nope, we're not talking about card Medicare rates. We're talking about taking all the savings from the whole system. Look at all those profits from United Healthcare. Look at Aetna, CVS. Those profits, we will now spend those profits. You will take that layer away. We will increase Medicare rates, right? So that's what they would do, Anthony. They're not going to keep Medicare rates here to get by. And they would say, we're going to have 5x Medicare rates, and that'll be sourced from savings from the old program.
SPEAKER_02You could have, you could have an administratively simple Medicare system. You could slash the entire Federal Register regulations around Medicare, and you could just do global budgets like they do in Canada. Each state gets a global budget. That would be administratively simple, and you would admittedly save a lot of money on administration. It would be incredibly inefficient. You would have massive shortages. You would have massive weight lines. You would have, I would, I think you would have terrible care because if you do something administratively simple like a global budget, you have no price signals whatsoever. You have no way for resources to be distributed in an economically efficient way, which means you're going to have waste shortages, inefficiencies. And so you will have a terrible system that is administratively simple, like Canada or like the NHS. So there's a couple ways to distribute resources. One is using the market and price signals, one is using administrative fiat. If you make it administratively simple, you could certainly save a lot, but it's not going to be an efficient system. So you know, that's that's when people bring up this point is like, well, why do these other countries spend so little on administrations? Because they have administratively simple ways to distribute their healthcare funds. Again, Canada uses a global system uh global budget, very administratively simple, but it leads to massive shortages in some areas of the country. We as Americans, I don't think, would accept that, which is why we have this highly complicated Medicare system, which is trying to restore some semblance of price signals to distribute resources, it doesn't do a very good job, so you kind of have the worst of both worlds. Right.
SPEAKER_00Right.
SPEAKER_01Yeah. So the interesting thing, well, first of all, this this it's a preprint. It is uh not peer-reviewed, not that matters much. But uh Rokana and a couple other folks kind of went all in on it. I think Medicare for All is a is a huge point for certainly the left, it seems like. The left wants to propose something, and I think they see it similar to Obama campaigning on Obamacare. Now it's saying, okay, we're gonna provide a positive vision of something and not just be anti-Trump and provide a Medicare for All vision. And here are the academic studies that suggest objectively why it is anti science to be against Medicare for all. So, you know, you kind of so that mortality number that saving 155,000 lives per uh per year if you move to a Medicare for all system, that really implies that. If you extend insurance to the uninsured, you're going to get a mortality benefit. Anthony, you're at a safety net hospital at UCSF. What what are your what are your thoughts on that?
SPEAKER_02Does not improve health outcomes, especially if it's in this Medicare for all system. Again, you're going to have to find some way to distribute resources. And so how are you going to decide who gets to see a doctor and who gets to get surgery or what area get get sort of what coverage? And when you have inefficient distribution of healthcare resources, you're not people are not going to get the care they need. And I think it's going to end up costing more lives than it saves. But then what people are going to say, yeah, I think it is. Because you're you're not going to have you're not going to have efficient utilization of healthcare. Not that we do now. I mean, healthcare right now is massively inefficient, as we've been talking about. But if you go to a system like Medicare for All, you're going to have shortages. People who need care are not going to be able to get care, just the same as in Canada or in the UK or even some of the Nordic countries, right? They they complain about weights as well. So I think you'll end up costing lives. And the argument's going to be, well, we're just not funding the system enough. And they're always going to say you have to just give more funds, just the same as public schools. The reason public schools aren't doing well is we're not funding them enough, even though we fund them a ton. So it's going to be the same argument. That's what they say in the NHS, is that the NHS simply doesn't have enough funds, and that's why it's not running well. That's the same argument they make in Canada on the left, is that it's not funding enough. So that's what it's going to come down to is it's going to be a worse system. People are going to be upset, and then they're just going to start saying, well, you just got to throw more money at the problem.
SPEAKER_01Yeah. But but I was right. No, no, no question. But I'm trying to get at this paper comes from this where this number comes from, um, the 155,000 lives saved, comes from one paper looking at a NHANES database which suggested a 1.4 egg mortality difference between uninsured and insured, and that's an adjusted difference when accounting for a couple of different major factors. And so I guess what I'm trying to get at is do you think there is that's simply it seems to be that there's a difference in mortality between uninsured and insured when you correct for things in this certain way. But are are there is it your experience that the uninsured population is very different than the insured population?
SPEAKER_02Not necessarily. I think it it's I mean, there are differences in the inpatient populations. We have very low uninsured population here in California because you can get presumptive Medicaid even if you're not here with documentation. So I I don't I don't think that there's a huge difference. Yes, I would like universal coverage. I don't want anyone to not get care because they can't afford it. But if you really need care, Mtala covers you, you can usually go to an ER. In most places you can get some sort of presumptive Medicaid. I don't think the six percent of uninsured Americans are what's driving up our mortality rate and affecting our life expectancy. And I don't think getting that six percent some sort of Medicaid card in their pocket, which doesn't offer any access to care because we have an expanded capacity will necessarily change uh the mortality rate in the US in any meaningful way.
SPEAKER_00Yeah.
SPEAKER_02So And I think I think you had a pretty good takedown of that one paper that showed that there is this mortality benefit.
SPEAKER_01Yeah, I mean look, it comes from this study, this Wilper study, the Wilper, it's a 2009 study, NHANES 3, 9,000 adults, 17 to 64 years of age. And they found, again, adjusting for a couple of different factors, the 1.4x mortality. Now, that's a point estimate. The confidence interval is 1.06 to 1.84, right? So that's a wide range. Uh it's not just it's not necessarily 1.4, so it's possible that it's a 6% difference versus a 0.84, 0.06 versus 0.84. And they chose 0.4, right? And they chose to model it on 0.4. Why not 0.06? But but there's another paper. They they this is what I mean by you have this Yale Impromotor study that shows this, and it's based on this one paper that is supportive to their point of view. However, they don't they don't mention a much larger study, the Kronik paper from 2009, that has 672,000 adults, right? And that paper has a point estimate of 1.03 with a confidence interval of 0.95 to 1.12 when you're looking at uninsured versus insured.
SPEAKER_02So you have they also didn't mention the Oregon Medicaid paper or the RAN study.
SPEAKER_01Yeah, exactly. Exactly. This is the insane thing. Like, okay, you wanted to pick some survey paper that showed whatever, okay. You picked it, but this is not science. This is propaganda to present just that as ground truth, right? Ground truth, Medicare saves will save 155,000 lives. This is this is a paper that is designed to be a talking point for politicians to push Medicare for all. This is not how science is done at all, right? This is anti-science. You didn't pick the much larger study, the correlation study, and then, okay, how do we decide which one it is? Well, we have multiple different randomized control trials, right? The RAN study, the Oregon study that have literally randomized people to insurance versus no insurance and have not found an actual mortality difference. So that's probably an important thing you don't want to leave out. But you can't do that because then you don't get the politician Rokana saying if we go to America rural, then we save 155,000 lives. It is complete baloney and it should be ridiculed really as such. Because look, it's just like there's a difference between unvaccinated folks that are unvaccinated and folks that are vaccinated. Those are two very, very different populations. All right. You can try to adjust via some confounders, sorry, via some markers for that, but you're never going to be able to adjust for everything. And so, so yeah, I mean, you can show me tons and tons of correlation correlative studies that suggest not being vaccinated results in X number of bad things happening, but you have to really account for the real difference in those two populations. And that's and it is not, it is not taking a leap too far to suggest that uninsured patients that are uninsured are very different than patients that are insured. Patients that are insured generally, because we have this weird work employment thing, right? They're generally working, right? Just looking at the the the cast of characters that work versus the cast of characters that don't work, those are two very different populations. Why aren't you working? What's happening? Are are there tons and tons of able-bodied folks that can work, or tons and tons of able-bodied fork folks that graduated from college that aren't working? The folks that are able-bodied graduating from college that aren't working, that is an extremely different population than those who are working. There's typically something going on either through some terrible thing that happened or whatnot. I mean, it's not that there isn't the random person that is totally able to work and doesn't work. But you know, just to give you an example of why those data points are so weak and why mechanistically it makes a lot of sense to have tons and tons and tons of correlational studies that show higher mortality, more bad effects in an uninsured population. But when you then go to randomize them, it's not that the randomization is screwing up, or it's not that uh uh the sample size selected isn't right. It's not that it's not a large enough sample size. No, there's lots of mechanistic reasonings behind, and any clinician who spends a lot of time taking care of uninsured, underinsured, insured folks will tell you that that there's those are very different populations. So anyway, rant, rant over.
SPEAKER_02Yep. Totally agree. And then uh the other interesting thing is is there's a of that six percent of pay people who don't have insurance, there's a substantial number who can afford insurance and choose not to, right? Avok Roy is a great example. Uh he's a conservative commentator. He says he's self-employed. I believe it was in a uh congressional hearing that he they asked all these people, do you have insurance? And he said, No, I'm self-employed. I have a HSA and I don't have coverage. So there's people who can afford insurance and who choose not to and who choose not to get it. And then the question becomes if we're going to go to a system of universal coverage with some sort of individual mandate like they tried with Obamacare, what's the penalty for not having insurance? If just getting rid of that uninsured population is the only outcome that matters, um, are you gonna and you're gonna have some sort of private market, you either have to default everyone into the government market or you have to have some sort of mechanism to force people to buy insurance. In Switzerland, what they do is if you don't buy insurance, they sign you up and garnish your wages, right? I don't think Americans are going to go for that.
SPEAKER_01Well, who knows? I mean, you we never thought that I'm sure people in 1930s London didn't think that they would wake up one day and physicians at least and would all be employees of the state as happened one fateful day in 1940. It's interesting that the Michigan uh back to Michigan here, the Michigan Senate candidate, Democrat Senic Senate can candidate Abdul Al-Said, I think. His wife is a psychiatrist. He himself is a MD, but never practiced.
SPEAKER_02Never did residency.
SPEAKER_01Never did residency, never practiced. His wife is a physician, a psychiatrist. He is, of course, pushing Medicare for all, saying we're gonna get this done. Um, but his wife is a psychiatrist, does not take Medicare or Medicaid. Uh-only. Yes, we only point out that there's not, to my knowledge, Anthony, you've made this point multiple times that all the Medicare for All legislation you've seen functionally outlaws the private practice of medicine.
SPEAKER_02Well no, so the the there are two bills that are on that are out there, both one in the House, one in the Senate. The Senate bill, uh obviously Bernie Sanders, the House bill, I believe, was uh the representative J Paul. Both of them allow cash markets to persist. If if just like in today's Medicare world, to do a cash pay market, you have to opt out completely as a physician with all the everything that goes into that. But there's no private insurance allowed. So it's either cash pay or Medicare. There's no private insurance allowed. Right, right.
SPEAKER_01Correct. Yeah. So and I think again, that that's the opening gambit. I think ultimately you end up in a place because they're gonna need physicians in this system, right? And over time, of course, as the system gets worse and worse, they're gonna erect walls for sure to kind of prevent folks from kind of leaving that system. Because if the physicians start leaving that system's en masse, then it just creates a bigger and bigger problem for the public public option that has fewer and fewer doctors within it. So you know the the case of Brian Day, who's an orthopedic uh I think orthopedic, right? Orthopedic surgeon in uh Canada who's gonna who's who's battled battled in court in Canada to tr attempt to allow physicians to pay him cash, and they're not allowed to pay him cash, you know, because apparently whatever he's offering is a covered service or or whatnot. So so you can get plastic surgery in Canada, but you can't can't get a covered service. Can't get your hip replaced. Can't get your hip replaced in a in a private place by paying paying more. You can travel to the United States and do that. You can't do it in Canada. So that's Medicare for All, Canada. So so yeah, so you know, there's some sick pretty significant restrictions that would be in place. And even if that early gambit, that the Gaffneys et al will say, Oh, no, no, no, we'll allow that initially, okay. Yeah, sure sure enough, the day is coming where they will they will probably make that much more much more difficult.
SPEAKER_02Well, it's all gonna be AI docs anyway.
SPEAKER_01Yeah, that that's true. So it's not gonna matter. So it doesn't matter. You know, the AI docs can mount uh their own revolution. The AI docs will probably be the AI docs will probably be much more successful at unionizing and organizing than the regular human docs. So there is that.
SPEAKER_02If you ever saw that old Gary Larson cartoon with uh Frank's neurosurgery where the guy's sitting outside of what looks like a butcher shop reading a newspaper, smoking a cigarette, that's gonna be that's gonna be me. It'll be Tony's neurosurgery. Cash only. If you don't want your AI bot, come see me. It's funny. All right.
SPEAKER_01All right, sir. We've spent uh an hour discussing the news of the day. Many, many rants down.
SPEAKER_02This has been great. It's been a pleasure. I hope uh I hope we didn't I wonder if we have any listeners left. But that would be funny.
SPEAKER_01We have so next next week we have not Charlie Munger, but Michael Munger.
SPEAKER_02Professor of economics and host of The Answer is Transactions Cost. So we are gonna get nerdy with the econ, and I'm super excited for this one.
SPEAKER_01Yeah, it should be it should be fantastic. It's next Tuesday at nine PM. We'll try to send out stuff on our X account through the week, uh, reminding everyone to uh tune in. But again, we'll also be on Spotify as well uh within a few days. So already. Thanks so much. Thank you.