In this episode of A Moment in Health, Dr. Ashish Jha spotlights a major shift in Medicare Advantage: UnitedHealth Group plans to drop 600,000 enrollees amid financial pressures, raising questions about the program’s size, costs, and overpayments. He then examines a new JAMA study on the VA Mission Act and its effects on access and quality of care for veterans. Dr. Richard Besser, pediatrician and CEO of the Robert Wood Johnson Foundation, who served as CDC Director during the H1N1 pandemic, joins to reflect on the once-bipartisan spirit of public health and the challenges of rebuilding trust after COVID-19’s politicization.

Dr. Jha discusses:

• UnitedHealthcare to exit certain Medicare Advantage markets as costs balloon, impacting 600K enrollees — Fierce Healthcare
• Impact of the MISSION Act on Quality and Outcomes of Major Cardiovascular Procedures Among Veterans — JAMA

About the Guest

Dr. Richard Besser is president and CEO of the Robert Wood Johnson Foundation (RWJF), a position he assumed in April 2017 following a long career at the Centers for Disease Control and Prevention and at ABC News. A pediatrician by training, Dr. Besser leads the largest private foundation in the country devoted solely to improving the nation’s health. Before joining the Foundation, Dr. Besser served for eight years as chief health and medical editor for ABC News, and as a leader at the Centers for Disease Control and Prevention (CDC), where he worked for 13 years. He served as acting director of the CDC during the initial response to the H1N1 influenza pandemic.

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. Ashish Jha here coming at you from Providence, Rhode Island on a cloudy afternoon with the podcast a moment in health where we talk about one data point, discuss one study and answer a question, and let's jump right into the data point. And the data point I want to talk about is a new data point that I just saw in a story out this week, and that number is 600,000 600,000 so what is that number? That's the number of enrollees that UnitedHealth Group, the massive health insurance company, is the number of Medicare Advantage enrollees it is planning on dropping because of its financial declines. So there's a bunch of things here that I want to take a minute to talk about. First of all, United Healthcare is the nation's largest provider of Medicare Advantage. About 9 million Medicare beneficiaries get their health care through United Health's Medicare Advantage Program. The pullback comes in part because seniors have a broad range of choices, and there are been some pushes against the massive growth we have seen in Medicare Advantage. Medicare Advantage, basically is private insurance companies running Medicare plans. Couple more quick things I want to talk about, because this will come up in the weeks and months ahead. First of all, UnitedHealth Group is massive. Their annual revenues is much bigger than the national health service in the United Kingdom. I mean, that's how big they are. Medicare Advantage is a is the program, as I said, private insurance companies running Medicare. There's a lot of mixed feelings about this. There are some real benefits of Medicare Advantage or some costs. One thing everybody who is a policy person agrees on is that the federal government overpays for Medicare Advantage. They pay too much, and that we have to come up with strategies to reduce healthcare spending on Medicare Advantage plans. That is a consensus view of the left to the center and the right, because it's true, and some of the

greatest, some best work on this has been done here at the Brown School of Public Health, but it's really been done by researchers across the country. We probably pay somewhere around $80 billion too much for Medicare Advantage. But as some of those cutbacks are coming, organizations like Medicaid, like United Health Group, are going to cut back on who gets Medicare Advantage, so 600,000 enrollees likely to lose Medicare Advantage. They can look from UnitedHealth Group, they can go to other insurers. They can stay with traditional Medicare. These people are not going to lose health insurance. They're just going to lose their care through United Health Group. Okay, that's your data point of the week. Now let's talk about the study of the week. The study of the week comes from the July 31 2025 issue of JAMA, the journal the American Medical Association. It's a fantastic study called impact of the mission act on quality and outcomes of major cardiovascular procedures among veterans. So as you might have heard in my previous episodes. I was on clinical service. I'm still on clinical service at the VA just wrapping up. It's been fantastic being back and taking care of veterans. But let's get to this study the mission Act implementation. The mission Act was basically created to give veterans more choices. There are veterans who live very far from VA hospitals, and the mission Act was passed by Congress to let veterans who live more than 60 miles away, or sorry, more than 60 minutes away from a VA hospital that they can go to a private hospital to get their care, and the VA will pay for it seems reasonable enough. And so a group of investigators asked the question, What has the impact been? Has it actually reduce travel time for veterans? And then what kind of care did veterans get when they landed in these other institutions? And this paper is fantastic. It has two main findings. One is that mission Act worked in terms of improving access, that it saved

approximately 30 minutes of travel per veteran when they went to a hospital outside of the VA makes total sense. There's a VA there's a non VA hospital close by now, you can go to it and and the mission act will pay for it. So that's the good news for the mission act. It improved access. There is, unfortunately, a little bit of bad news. They also looked at things like major cardiovascular outcomes and adverse events, and said when you ended up in a different hospital, what happened to your care and what they found that for patients with cardiovascular disease undergoing angioplasty, bypass surgery, the mission Act was associated with worse clinical outcomes. Why would that be two reasons. I mean, look, most of these things are not super time sensitive. If you need an angioplasty, you need a bypass surgery, it's not time sensitive. People go to a closer place for convenience. Their family can visit them, but I've talked about this previously. The data suggests that the VA hospitals provide better than average quality of care. So if you end up in a local hospital, on average, you're going to end up with a. Lower quality hospital. So yeah, less travel time, better access, but potentially worse quality. That's what this study finds. And so these veterans ended up having worse outcomes because of the mission act, despite saving a lot of time on travel. So it's a bit of a mixed bag, and the things to think about is, how do we improve access without harming quality? That's going to be the important work for the future,

all right. And now for the question of the week, and for the question of the week, I have a very, very special guest. I'm very excited to have Dr rich besser. He's a pediatrician. He's the president and CEO of the Robert Wood Johnson Foundation and formerly Acting Director of the CDC, certainly during their initial response to the h1 n1 influenza pandemic. Rich has had an extraordinary career, both in medicine and public health, and I am super excited that Rich is here. So Rich, thanks so much for coming

on. Oh, it's it's great to be here, as she's looking forward to it,

all right. Well, so here's my question for you. You've had this broad perspective on public health, as I said, from CDC to running now, arguably, I'm not even sure, arguably, clearly, the most important domestic Health Foundation we have in the US. You have watched public health through the pandemic. How do you see the current moment we are in rich and what do you think is needed to get public health back on its feet? So, big question, broad question, how do you see where we are, and what do you think we need to be doing in the public health community to restore confidence and make public health more effective? Yeah,

I mean, it's a it's a great question, which is probably why it's your question of the week. I've had the privilege of of of working in public health my entire career, and I think that there was no part of my career that I was prouder of than the 13 years that I served in in government and I worked at the at the CDC under Democratic administrations and largely during Republican administrations. And one thing was was never in doubt for me, and that was that regardless of the administration, the approach might be different, but both Republicans and Democrats cared about the health of of the public. I led emergency preparedness and response at CDC for four years during the Bush administration. I started the day Katrina hit New Orleans, and ended that job when President Obama was was was elected, and when I would go to Congress and talk to people on both sides of the aisle about public health. Everyone cared. Everyone knew that public health was was that tool of government that ensured that people in communities, that their health was was protected, that diseases were prevented, that there was the ability to respond in in a crisis, and that was never in doubt. When I led the agency at the start of the the swine flu pandemic in 2009 the government came together. Everyone was unified around that response and was so grateful for public health at the federal, state, local, tribal, territorial level, it was a real high moment in public health. And where we are now is unrecognizable from that period. And I think, I think what, what what happened was during covid, we saw politicization of public health in a way that had never happened before. We saw people in in political office who who had an opportunity to gain from dividing the country around public health and what public health was asking people to do. And so the question for me is, how do we get the politics back out of public health? And because you talk to people in communities and

they still want the same things. They want to be healthy. They want their health to be protected. They want to they want to know that their kids, when they go to school are going to be safe, and that when they go out for a meal that the food isn't going to make them sick. All of these things that public health does. And I think it's important for us to to learn how to talk and listen to people around what their needs are, and to try and do what we can to take some of the heat out of this in terms of the politics, because it's really easy to play now into that narrative that one party is all about undermining public health and the other party is all about supporting public health. But if we can talk about what public health does, yeah, and learn to listen, I think we can, we can make progress. It's going to be slow, because, you know, once trust is is destroyed, it's extremely hard to bring it back. But if we can, if we can also, you. Tell the stories of what happens when public health isn't there. One of the challenges of public health is that the better public health is at doing its job, the less visible it is, and so the support goes away. I worked on tuberculosis control when I was out in San Diego, and it's the classic example of a an area where the better it is, the less support there is for funding, and then the support goes away, and the disease comes back, and you get the funding back. We don't want to have to go through that, but unfortunately, I think we're going to be going through that with vaccines and approach to vaccination and needing to document and tell stories. What happens when people aren't vaccinated, but then coming back and finding a way in so that there's room for people to move who may have been supportive of some of the policies to dismantle public health, so that they can come back in and say, Yeah, we support this. It's

one follow on question for you. You raise an important point. And I love the way you started with the sort of super bipartisan history of public health, which I've always believed in. And I remind people that in 2019 the most vaccinated state in the country was Mississippi, also one of the most conservative states in America. So I don't want to hear about partisanship and vaccines as somehow that's a natural thing. It isn't, but it has become more partisan than I think any of us are comfortable with. And I believe, firmly, I've spent a lot of time up on the hill in the last six months talking to Republicans and Democrats. They care about the same things at the end of the day, how do we do a better job of reaching people who feel like public health has become partisan to really make the case that the things we work on affect red and blue and purple communities across the country. And any further thoughts on bridging that biparti, that partisan divide that you and I both hate because it's not actually in the history of public

health? Yeah, I think some of it is, trying to find trusted messengers, and for each of us who we trust is a little bit different. Yeah, one of my favorite things is to go on C span, because it's call it, and you're talking to people from across the political spectrum. And the message I tend to give people is the same. Don't listen to political leaders. Don't get your health information there. Talk to someone you trust, talk to your doctor, your nurse, your pharmacist, someone who you trust, and see what they recommend, because all it doesn't matter where you live, your healthcare provider is going to be supportive of the basic tenants and approaches of public health and and I think supporting the right messengers is one way to get there, because I know for some people I'm a good Messenger, and for some I'm not, and that's okay, yeah, but I know that when I practice general pediatrics, my patients often came to me with questions, and they tried and they trusted me to answer those. And I wasn't coming at it from a political perspective, you know, I was talking about them and their child and what they can do, and I think that's probably the best way in

I love that so listening more than just talking, finding trusted messengers, making the case and reminding people of what is lost when public health is lost. And I love your point that you made rich, which I don't know, that I've heard enough people make, which is creating the space for people who've moved away from public health to come back without trying to shame them, without trying to say, I told you so, but actually just creating an openness that says, Look, you may have been disappointed with what some of the things that happened in public health come back. Let us remind you of the core work that we do. I think that openness is very, very important. We see very little of that. And

I think another piece of that is having the ability to admit that there are things that public health has done and continues to do wrong. Yeah, the foundation, a lot of our work was around trying to move public health in the direction of meeting the needs of everyone in every community, because it clearly wasn't. So this isn't about going back to what we had, about imagining, well, what could public health really be to meet the needs of people in every community.

Awesome, Rich. Thank you for your leadership at RWJ. All of us in public health look to it, as I said, as the premier organization, really focus on the health of the American people outside of the CDC and the government. And thanks so much for coming out today. This was a great conversation. I really appreciate it.

Thank you. It's really a pleasure.

All right, there you go. Another episode of moment in health where we talked about one data point, 600,000 that's the number of people that UnitedHealth Group says it's going to drop from its Medicare Advantage programs. It was a chance for us to talk. Little about Medicare Advantage and why it's such a behemoth of a program and why it needs reform. We discussed one study the impact of the mission act on quality and outcomes for major cardiovascular procedures among veterans, published in July 31 issue of JAMA, basically showing the mission Act, which allowed veterans to get care closer to their homes if they live more than 60 minutes away from a VA hospital worked in terms of veterans, went to closer places. Their travel time decreased, but they came with a cost, not just a financial one, but they ended up at on average, worse. Hospitals ended up having worse quality, worse clinical outcomes, so not great. Better access is good. Worse outcomes is not so good. And then we heard from Dr Richard Besser, pediatrician, public health leader extraordinaire right now, the President, CEO of the Robert Wood Johnson Foundation, not just right now, has been for about eight years, was the Acting Director of the CDC, has really had a storied career in public health, and he reflected on the journey of public health how it has always been deeply bipartisan Republicans and Democrats. Turns out, everybody cares about the health in their communities, and it has the issues that public health cares most about have never really been particularly partisan, but that has changed somewhat during the pandemic because of the deep politicization of public health that happened, and he laid out the strategies for rebuilding trust, which is really about trying to de politicize things, more storytelling, explaining what we do, engaging with trusted messengers, and also acknowledging some of our own shortcomings and missteps and how we plan to evolve. I thought it

was a really nice prescription, consistent with some of the other things we've heard from other people like Jennifer Nuzzo and others in the past. But it was great to have rich on laying out exactly how public health needs to get its mojo back. And I suspect if we do those things, it will. Thanks a lot for listening. Thank you, Catherine Beggs for the music, and I look forward to seeing all of you or talking to all of you next week on another episode of a moment in health where we talk about one data point, discuss a study, answer a question. Have a great week, everybody.

You.