In this episode of A Moment in Health, Dr. Ashish Jha unpacks the projection that the United States will spend $64.9 trillion on healthcare between 2025 and 2033. He highlights a major Danish study showing no link between aluminum in childhood vaccines and chronic diseases. Professor Erin Fuse Brown joins to explore whether the corporatization of healthcare—through private equity and profit-driven consolidation—can truly reduce costs without sacrificing care quality.

Dr. Jha discusses:

• National Health Expenditure Projections, 2024–33: Despite Insurance Coverage Declines, Health To Grow As Share Of GDP — Health Affairs
• Aluminum-Adsorbed Vaccines and Chronic Diseases in Childhood: A Nationwide Cohort Study — Annals of Internal Medicine

About the Guest

Erin Fuse Brown is a Professor of Health Services, Policy, and Practice at the Brown University School of Public Health. Her areas of research and expertise include health law and policy, health care finance, health care consolidation and prices, the Affordable Care Act, single-payer and public option health reforms, ERISA preemption of state health laws, consumer financial protections for patients against surprise medical bills and medical debt. She also serves as a consultant to the National Academy for State Health Policy to provide legal and policy resources and draft model laws for its Center for Health System Costs, funded by Arnold Ventures.

About the Host

Dr. Ashish K. Jha is the dean of the Brown University School of Public Health.

Music by Katherine Beggs, additional music by Lulu West and Maya Polsky

Hey everybody. This is Ashish Jha for a moment in health. I'm coming at you today from the Brown School Public Health Office of Washington, DC, and we are in the podcast a moment in health where we talk about one data point, I discuss one research study, and then answer one question, and I am going to go ahead and just get started. And the data point I have for today is a big number, a very large number, and the number is 64 point 9 trillion. That's $64.9 trillion and what is that? That is the expected amount of money that the US is going to spend on health care between 2025 and 2033 that number comes to us from the actuaries at the Center for Medicare and Medicaid Services, the people whose job it is to make these projections. It's an extraordinary amount of money, just an extraordinary amount of money, and we're past $5 trillion a year now, and there is lots of reasons we believe that healthcare spending is going to accelerate in the years ahead, driven both by demographics, our population is getting older, and that's a good thing. By the way, older populations mean people are living longer. We also have a whole lot of miracle therapies coming, GLP ones, gene therapies, other cell based therapies, those are going to be expensive, and when you think about a number like 64, point 9 trillion and ask the question, well, who's paying all of that? It may seem like, well, somebody else is going to pay for it. Turns out, we're all paying for it. We're paying for it through our taxes. We're paying through it for it through foregone compensation, if we're getting employer based insurance, and we're paying for it directly out of our pockets, because there's a lot of out of pocket costs in healthcare. So in healthcare. So my hope is, in the upcoming weeks and months, I'm going to talk to you about some of the data out there on what actually we can do to drive that number down. Because that's 64 point 9 trillion, or basically 65 trillion over nine

years, it is going to take it very, very hard to cover everybody, to not bankrupt people and not to continue to run very, very large deficits for our governments. So this is a huge challenge that we're going to want to talk more about in the in the weeks and months

ahead. Okay, so that is your that is your data point. Let's now move to talking about the study of the week, and the study of the week is comes to us from Denmark. It's aluminum absorbed vaccines and chronic diseases in childhood, a nationwide cohort study published in the July 15 issue of the Annals of Internal Medicine. This is a great study, really well done, 1.2 million kids in Denmark now. Why is Denmark a great place to study this? They have fantastic longitudinal electronic health records on their entire population, and so they will track people. And what they found was that they looked at kids and aluminum exposure from vaccinations. There's has been in the news. RFK has been for years talking about how aluminum is bad in vaccines, and so they looked at aluminum exposure from vaccines, cumulative exposure in the first two years of life, and said, did any of it lead to increased rates of any of 50 chronic diseases? And they found no link, no link to 36 different autoimmune diseases, no link to allergy or asthma, no link to neurodevelopmental disorders like autism and ADHD and so they really did this across the board. And when you have a study that big, that well done in a national cohort from Denmark, you would think this would put this issue to an end. Now, of course, there can be people who are going to continue to try to bring this up, but it but it actually raises for me another important point to make, which I think is worth understanding, and it's a point I have made before, and I'm gonna make over and over again, which is one of the things that you learn early in medical school, is almost anything can be toxic. Almost anything can be safe. It depends on dosing. Take something like arsenic. There's arsenic in our water. That sounds awful, but it's at such low levels that we don't think it causes much in the way of of harm. People talk about aluminum as a neurotoxin, sure, if you have massive amounts of aluminum, yes, but the cumulative

dose of all the vaccines that kids get is still so tiny that has essentially no health effects, no negative health effects, on children, while obviously the vaccines themselves have extraordinary positive health effects on kids. So next time somebody says something like, Oh, this is a neurotoxin, or oh, this is bad, what you're usually getting is somebody who wants to spread bad information because they don't understand the issue of dosing. And dosing is everything, and the levels of aluminum in these vaccines is so tiny that has no negative health effects at all. That's what this Danish study from the July 15 issue of Annals of Internal Medicine tell

us. You. You all right. And now for the question of the week, and to answer the question of the week, we have a colleague and friend, Erin Fuse Brown, who is a professor of health services research, policy and practice here at the Brown School of Public Health. Aaron is a lawyer, a legal scholar who thinks about the health care system and has been writing pretty extensively about a range of issues. But the issue that I really want to talk about is this notion. She had a New England Journal piece recently about corporatization of healthcare, private equity, other types of investments. And the question I have for you, Erin, first of all, thank you for being here. Yeah, happy to be here. The question I have for you is a lot of people don't love all this corporatization of in healthcare, but are there ways in which you think corporatization of healthcare could actually lead to lower healthcare spending without harming quality?

Erin Fuse Brown: I really wish there were that that were the case. I think if we could find examples of that, that would be the exception, not the rule. And I'm going to quote or grab a quote by UVA Reinhart that every dollar of health care spending is someone else's income. And so when we think about lower spending, lower cost care, more efficient care, all of those innovations sound great in practice, and corporatization and the private markets, and letting private market forces work is a great idea in practice, but what we see is that a lot of the policy efforts to do so, even a lot of the payment policies, really don't result in much savings, because, again, it's cutting someone else's income, and the someone else is usually a powerful either health care entity or, increasingly, a Corporate Conglomerate that owes its shareholders a duty of maximizing shareholder returns, okay,

but let me ask a question as a follow up. There are other places where people make more profit by by lowering costs. I think about Walmart. Walmart, I mean, maybe their goal is to maximize revenue, but their actual goal is to maximize profit, and one of the ways they have done it is by making stuff cheaper and then gaining market share and having a low cost, perfectly fine quality retail store, Amazon. There's a bunch of other examples. Why doesn't that seem to be a possibility in healthcare? Why couldn't a corporate entity come in and say, we're going to lower health care costs, maybe take a little hit on revenue, but then we will be able to grow the market, and our profits will be great, but we will be delivering a high quality, low cost product to the marketplace.

There are a couple of reasons why I think we don't see sort of a Walmart of health care. One is, is that health care is extremely labor intensive, so it is difficult to cut costs in a way that still maintains quality. Because usually what we see is, when, say, a private equity company comes in and buys up a hospital, they are trying to cut costs and increase revenue to maximize profit, the way they cut costs is to cut staffing. The moment you cut staffing, you see quality take a nosedive. So that is difficult to do that sort of model of cut costs, improve scale, cut out the, you know, the the middleman, and increase efficiency in that way. And there's a lot of promise of that, but it's hard to see, like I said, large scale examples of that working. And another reason is that healthcare isn't shoppable for the most part, the way consumer products in, you know, in a Walmart store are, and so we as the patients, the purchasers, there are so many players with, you know, our employers, our you know, the the insurance companies, all the different middlemen you Know, that work along the way, it's very difficult for a consumer, a patient, to really shop for health care, and to exert those same market pressures that we see work in a retail setting, in the health care setting, because health care isn't shoppable. You're not comparing prices. You're going with what your doctor recommends. They don't even know what the price is, and for the most part, you're just trying to navigate what is an increasingly opaque system where nobody's interest is cutting costs except for your own. Yeah.

Okay, so final bit of this, so corporatization of healthcare that we're seeing more of overall as of today, middle of 2025, I understand that there's a lot of heterogeneity. What's your best sense of like, what the impact of that has been on both cost and quality? Kind of put the what the evidence we have together, what's your best assessment of what the impact has been to date?

I think that the overall impact, it's pretty clear that corporatization, if we define that as sort of rising levels of consolidation by profit seeking, large consolidated entities, that the main impact that we can definitively say is it's increased prices and spending. And it's increased prices, it's increased volume. It's increased a lot of the revenue generation is through. To increasing the market share and jacking up your prices, doing more doing more intensive work, and so we don't see a lot of declines in this. This sort of efficiency enhancement on the quality front, as I mentioned before in facilities, corporatization, whether that's private equity or other types of for profit, investment almost certainly has a negative impact on quality of facilities because of the labor cutting that happens. The staffing cuts almost certainly immediately leads to just less, lower quality care, and we have lots of evidence that in hospital settings and in nursing homes, mortality adverse events go up in the physician practice, contacts and other outpatient services or things like medical devices or technology, we have less evidence that there's a negative impact on quality. It's more mixed, but we do see that. You know, again, prices go up, costs go up, spending goes up. So we know that that's the case, and we're not getting a lot of impact in a positive direction on quality either. So for all that extra spending, we're not getting more or better care

Great, well, and thank you for coming by and explaining all of that and answering really the key question on this, which is not only what have we seen, but what prevents us from kind of realizing the at least the hoped for benefit of more efficiency, higher quality, Lower costs that we see in lots of other markets? The lack of shopability, the labor costs, the other structural factors really making that hurt, that was fantastic. Thanks so much for coming by. Thanks for having

me. There. You have it another episode of a moment in health where we talked about one data point $64.9 trillion just an extraordinary amount of money, $64.9 trillion that's how much we're gonna be spending on healthcare over the next nine years. 2025, through 2033, according to the CMS actuaries, we talked about one study, the 1.2 million kids in Denmark, looking at their exposure to aluminum from vaccines in the first two years of life, and the association with a whole host of chronic diseases with the short and sweet answer of there is no association, and a reminder that at the end of the day, the dose matters, the amount of aluminum in vaccines is so minuscule that it absolutely has no negative, harmful effects. If it did, we'd see it in a study that big. Last but not least, we heard from my colleague and friend, Erin Fuse Brown professor here at the Brown School of Public Health, and we talked about corporatization. She has a fantastic piece in the New England Journal, an op ed essentially a perspective on this. And the question I asked her is, could we imagine corporatization, private equity, other types of systems could lead to lower healthcare spending. Everybody worries about higher but could it lead to lower healthcare spending without harming quality? And Aaron was pretty skeptical of it. I mean, her point, she had 2.1 was generally lower spending means somebody's lower revenue. And most private equity firms are not in this or try to lower their revenue. They do want to cut their costs, which they tend to do by cutting labor, which usually has a negative effect on quality. And the second question I asked was, well, in other markets like retail, we do see progress where private companies do come in and lower costs. And her point on that was, we just don't see much evidence that healthcare is shoppable, and so if somebody made a low cost healthcare product, it's not really clear that it would do well in the marketplace. I will just put in

my little bit of editorial on this. Erin is brilliant, and you got that sense when you told when we heard from her, and I completely agree with her points. I still remain optimistic. Now this is a data free statement. I can't show you evidence that this is true, but I still remain optimistic that we are going to get innovative providers who can deliver health care at lower cost, come into the marketplace and figure out how to make the market work for them as one means of lowering health care spending. Has that happened not as much as we need to see it. Am I convinced that's going to work. I'm not, but I am hopeful that we will see that kind of entrance, and if we do that, has some meaningful chance of lowering health care spending and maybe making progress on that $64.9 trillion All right, thanks again for listening this week music from the great Katherine Beggs, as discussed earlier. Thank you, Katherine and I will be back next week with another data point, another study, another question in the podcast, a moment in health.

You.