Governor Jim Doyle, Counsel and Health care Lawyer with Foley & Lardner LLP
What role will state policy makers play in shaping healthcare? Governor Jim Doyle reflects on the future of healthcare and the role of governors in healthcare policy. He discusses the unresolved question of whether healthcare is a right for all Americans or an individual responsibility, emphasizing the trend towards healthcare being considered a right. Governor Doyle believes that technology will play a fundamental role in healthcare transformation, making it more efficient and accessible. He advises new governors to focus on getting people covered and addressing social determinants of health. In 2049, he sees governors continuing to play a crucial role in shaping healthcare policy and addressing challenges related to end-of-life care and increasing life expectancy, within the context of a federalist system that values state autonomy.
Governor Jim Doyle is of counsel and a health care lawyer with Foley & Lardner LLP where he provides strategic advice and counsel to clients regarding policy and regulatory issues in the areas of health care, energy and other highly regulated industries. Gov. Doyle served as the 44th governor of the state of Wisconsin (2003 – 2011). Governor Doyle was recognized as a national leader in health care, energy, natural resources, biotechnology and many other areas.
He has worked closely with the White House, high-ranking Administration officials and other governors. He has a deep understanding of the new laws and regulations being considered and adopted regarding health care and energy and works with clients to anticipate and comply with the evolving regulatory framework.
Prior to his election as governor, Gov. Doyle served 12 years as Wisconsin’s attorney general. He led the attorney general’s office representing the state in all matters. Gov. Doyle has led and coordinated major multi-state efforts and argued three cases before the U.S. Supreme Court. Prior to that, he was the Dane County District Attorney and a lawyer in private practice.
Show Notes
Governor Jim Doyle shares his health care background. [03:33]
Will health care be a right for all people and will public policy reflect that in 2049? [09:54]
What will our healthcare system look like in the future? [11:34]
What role will technology play in health care? [14:30]
What did we learn from our fragile public health system during COVID? [19:50]
Do people trust their doctor? [24:00]
What should a new governor be focused on to help their state create a strong healthcare system? [27:44]
What role will governors play in health care in 2049? [31:51]
Transcript
Jason Helgerson 00:04
I'm Jason Helgerson, and you're listening to Health2049.
Governor Jim Doyle 00:07
I think really, when you look at 2049, the biggest unresolved question for the country is, is health care a right? Is it something that we should be assuring all Americans of or is it some kind of individual responsibility that people have to take care of and that political fight is one that goes on and on and on. But if you look at the trend, the trend has definitely been more going towards the idea that it's a right.
Jason Helgerson 01:52
Today's guest is a highly esteemed figure in American healthcare having held one of its most important positions. Governors across America play a crucial role in shaping health policies and overseeing their state's largest health care purchaser, Medicaid. Meet Jim Doyle, the 44th governor of the state of Wisconsin who dedicated eight years to public service in his influential role. Throughout his tenure, Governor Doyle spearheaded transformational changes in Wisconsin's Medicaid program, leading to historic levels of health care access. When he completed his term an impressive 98% of Wisconsin residents, including all children had access to affordable health insurance. Presently, Governor Doyle brings his wealth of experience to the legal profession of counsel and a health care lawyer at Foley and Lardner. In this capacity, he offers strategic advice and counsel to clients specializing in policy and regulatory matters concerning health care, energy, and other highly regulated industries. While numerous individuals express opinions on health care structure and administration, only a few have actively shaped and executed it. Governor Doyle is one of those exceptional individuals, making us incredibly fortunate to have him as today's guest on Health2049. I'm Jason Helgerson, and you're listening to Health2049 and it's my pleasure to welcome Governor Jim Doyle to the program. Governor Doyle, welcome.
Governor Jim Doyle 03:21
Well, thank you, Jason. It's great to be with you again.
Jason Helgerson 03:25
That's fantastic. Well, first off, we always like to ask our guests to tell the audience a bit more about their interesting background.
Governor Jim Doyle 03:33
Well, the first thing I want to mention to those who may be listening is Jason was a Medicaid Director in my administration. And in that regard, really led the effort when we made the biggest at that time, the biggest expansion of Medicaid in the United States with a major waiver from the Bush administration at the time, that as Jason indicated, led in successive steps, we went through a number of them, but to having almost everybody in Wisconsin with access to affordable health care, and most people actually, in the mid 90% actually having health care. So I want to thank Jason for that. I will say I had to order him to take the Medicaid job. He was so valuable to us in some other areas, including economic development that he thought he wanted to stay in. So I feel a little responsible for how well he's done since moving to Wisconsin
Jason Helgerson 04:32
It's very true, Governor. It's a very true story.
Governor Jim Doyle 04:35
But I am really happy to be part of this discussion. I will just say that when I ran for governor, I had been the attorney general and in that world for 12 years before and a number of really significant health care issues had been focused on in the Attorney General's Office, most notably the fight against big tobacco. I was part of the lawsuits that were brought, we're the biggest in the country and they've had just a remarkable change in the health care of people in America. I just saw a numbers I may be off on this a little, but I'm sure there are basically right that in the mid 60s, into the 70s, about 60% of Americans over 60%, I think it was 64% that I saw smoked. And that number is down to 19. And it's falling very rapidly as older smokers age out of it, to put it euphemistically age out of it. So I really in large part got elected governor because of how the prior Republican administration in Wisconsin had handled the tobacco settlement that I had delivered to them. So health care was critical. But in my years, elected 2002, and re elected in 2006. So that first decade of the 21st century, health care really became in many ways the dominant political issue in America that continues to this day to be. So as Governor, we, as I indicated, had a major expansion of Medicaid. It was really innovative programs that again, Jason deserves a lot of credit for, to reach people who otherwise had not been eligible. Since being governor, I've continued to be involved in health care as a lawyer and consultant. But also I was the chairman for quite a number of years of the Kaiser Family Foundation, one of the real premier health policy, and now the largest health news bureau organization in the United States. And I'm on the board of several health companies. And maybe most notably, for this discussion, I'm on the board of Epic Systems, and of Exact Sciences, which is a company that really developed but is now pretty well known as cologuard, but other diagnostic, as well. So I've seen the side of it from the private business, as well, a little bit deeply involved in that. I will say, I will go wherever this conversation wants to go, but I think really, when you look at 2049, the biggest unresolved question for the country is, is health care a right? Is it something that we should be assuring all Americans of? Or is it some kind of individual responsibility that people have to take care of. That political fight really is, as you know, Jason, you've been in the political world for quite a number of years is one that goes on and on and on. But if you look at the trend, the trend has definitely been more going towards the idea that it's a right. So I think of the Epi Pen dispute a number of years ago, where people just generally were outraged, that private industry would put a price on the absolutely necessary health product that prohibited people from having it and I would say there was almost universal, both Republican and Democratic in political terms, but also just ordinary people just were outraged at the idea that a private company could put a cost on that. And I think that really demonstrates that I think most people culturally in this country believe that people ought to be able to get health care, although the rhetoric often goes in the other direction. But I think as you look at 2049, it seems to me the movement has been very much towards that. And so on the sort of political side of it, I think we'll continue to have fights for many years. But the long arc of this is towards health care for all and we are achieving it in fits and starts, large jumps forward for certainly in the 60s with the adoption of Medicaid and Medicare, large jump forward with the Bush administration with Part D, very large jump forward with Obamacare, but always resistance coming back against each of those. So I think that's kind of the long term political fight that we're gonna see going on into the middle part of this century.
Jason Helgerson 09:25
Well, that's great. So let's dive in a bit deeper on that question. I agree with you, governor, that the long arc history definitely bends towards health care being a right in the United States. Do you think we will achieve that by 2049? Do you think that by 2049, roughly 30 years in the future, there'll be consensus or near consensus in the United States that health care is right and as a result that public policy will reflect that?
Governor Jim Doyle 09:54
I think so. I mean, there may not be a moment where it's enshrined in the Constitution, that it's a right. But I think right now, it is pretty much universally available except for pockets of people that we, for various reasons–poverty, race, and others have left behind in this. So I think if you look at the big picture, we have largely achieved it with some very, very significant gaps that have to be addressed. Now, whether we've achieved in a way that's cost effective, equitable, delivering the best service in a timely fashion, those are all really good questions, which I think there are a lot of problems, and how we actually deliver it. If we just look at it come to a point, I think where we have it largely except for is significant pockets that we for various reasons have left behind.
Jason Helgerson 10:54
So around that, too, do you think that the way we get to it being a right in this country is through further incremental changes, meaning that the core structure which is a mix of government programs, employer sponsored insurance, some individual insurance sometimes subsidized with tax credits, like through Obamacare, that that sort of structure is what we still see in 2049 and with some of the further gaps being filled? Or do you think that there are more structural changes in how we purchase health care services, and the role of government in the purchase of healthcare services?
Governor Jim Doyle 11:34
I think there'll be some pretty fundamental changes, they won't happen in just a single moment. I think it's getting harder to justify insurers making significant money off of just administering the system. On the other hand, I guess maybe as a Democrat, this is a little counter thinking, but I do think when you look at the role of private companies, you can see that much of the real innovation, particularly as technology becomes more and more of the focus of this, it moves, I believe, moves much faster in an entrepreneurial environment than it does in large national kind of health systems. So I think we're going to continue to have a mix of all of this. But how the mix is balanced. I think we're gonna see some significant changes, I believe that we will end up at least, at a basic kind of Medicare for All idea that there's a basic insurance policy that all Americans have that the government pays for. Whether the government then delivers that, even 25 years out, I think it's hard to see in America, that it'd be the government delivering it in the sense of a large European national health system. But I do think there will be a basic government payer for a basic policy. It seems to me that's really where we've been headed. Although that gets beaten back pretty forcefully, every time Bernie runs on that issue and gets pushed back all the time. Well, actually, it's kind of clear what he runs on. But whether it's a big national system or Medicare for All, I think we probably in America end up with a Medicare type of system for everybody.
Jason Helgerson 13:37
Okay. So the role of technology and as you mentioned, even the work you're doing today is very focused in the sort of technology and innovation space of health care, both actually nationally, and the companies, you're on the board of sell internationally, and so we often get into this question about the role of technology in health care in 2049. What is your view relative to the role it's going to play? Are you seeing it as really, truly transformational in the sense that the actual patient experience or the role of the provider, the physician, the nurse, will be fundamentally different in 25 to 27 years? Or do you see technology is playing a role but not quite so fundamental in terms of really changing the user experience?
Governor Jim Doyle 14:30
I believe it's fundamental. And I think if you just look back at the last 25 years, I know you're the son of a doctor, but think how critical a doctor was 25-30 years ago in reading all the journals trying to stay up with all the most recent information, hearing about a difficult case from going to a conference and hearing about it was something that happened three months ago in another state and then trying to follow up to see if that would apply to the difficult case that this doctor is dealing with. All of that is done now with the data that's available. Those difficult cases can be found in the matter of seconds. The doctor, this already happens, the doctor just on the electronic health chart, can see what the recommended treatments are, for something the most up-to-date information is immediately at people's fingertips. So the great value of a doctor who had, and I will say largely his head at the time, but now his or her head, which was absolutely critical, you were just lucky to be with a doctor who was working at this all the time, trying to stay up-to-date that's now available to every medical professional in the world, there is certainly in most in most countries. So I think that's already changing and that's only going to continue to change. Does anybody doubt anymore that the most important thing you do in the annual physical is going to give your blood test and then the doctor looks you over a little bit. But the most important thing is what that test is and what we can determine from that test. So I think the diagnostic world is changing rapidly and obviously the data world is changing enormously. This was certainly in your days when you were in Wisconsin, that we had one of the best public health reporting systems, we always bragged it was the best in the country, because we had automated much of it. But the automation was hospitals sending information to the county, the county sending information to the state, and the state sending information to the CDC. And while we had automated most of it, and we would brag about that, there were states that and I assume they may still be there that had paper records in their county health department's. So when COVID comes around, to try to deal with that system to find out what's happening with COVID, how many hospital admissions were there yesterday for COVID? What happens to people who got the vaccine age 50 years old who have certain comorbidities? What happens to them six months out from the vaccine. That was only available months later, that is now available in real time. So I think technology is changing this dramatically. And also, just the advances of science. People often say it's so expensive, compared to back in the 1960s, I could go and pay a doctor 50 bucks and get a visit. Well, that's true, but you weren't getting nearly the service that you get now. Our health system, if you look at where we were 25, 30, 40 years ago, compared to now, it's a very, very different system, it's a much more effective system, the treatments are better, the technology is better, the data is better, the diagnostics are better. With AI and other technological advances that's gonna move even faster than it has over the last 25 years.
Jason Helgerson 18:28
Yeah, actually one area, you just got into a little bit that I wanted to pick your brain on and see what your thoughts are is in the public health system in the United States and governors also really, to great extent, serve as the chief public health officer for their states, and are the ones who manage the response to public health emergencies. And I think that role was probably underappreciated until the pandemic, to the degree to which, and we saw across the country governors responding to the pandemic in fundamentally different ways. But I think we also saw some of the weaknesses of that public health system in the United States. Especially when it was comparing the US response to what was happening in other countries, but what are your thoughts on the public health system and what that system looks like in the future? Do you think we will learn from the mistakes or the underinvestment in that system of the past, things that showed up very clearly in the pandemic? Or maybe are you not as optimistic that we will really use this crisis in this horrific incident as a learning experience for this fragile system we call public health?
Governor Jim Doyle 19:50
That's a great question and my opinion on this isn't any better than anybody else's. Our response was very heartening in many ways and very disheartening. But clearly the under investment had us in a very bad place. Just our crisis, our triage, public health system wasn't ready to go by any means, as we know what happened in New York City and in some of the early places where the horror was really just there hitting people, as they watched people being carried out of their homes, and so on. So I hope we've learned that but I'm not sure. I've often thought, who is going to get hurt politically out of the response? So if you look at the DeSantis campaign, right now, he's going after Trump, because Trump somehow in the DeSantis world was too accommodating to the public health people on COVID. DeSantis stood up against all this public health garbage that was coming on. And then you look at the statistics. I noticed that, I don't want to get to picking candidates here, but the Governor Sununu, Republican, of New Hampshire, New Hampshire had one of the absolute best records. So I would love to see those two face off on a COVID debate. Because I looked at these numbers once and I don't know that I remember them exactly. But Florida basically four times the people die per capita that New Hampshire had. So politically, how does that play out? Is it good for the governor who really did follow protocols, put in lockdowns at the critical times, require masks? Do all they could to get people vaccinated? Is that Governor gonna be rewarded? Or is it the governor who said I stood up against all of that? And I think that's a big political divide in America. And I'm not sure where it comes out. That political divide, I think, is going to kind of determine whether we learn and do things based on COVID or not. You've probably heard this, but I have heard people say it, it's almost a joke, to say, we're never going to do that again. We're never going to do that COVID thing again. Well, I hope not. But we really don't have any say over that, if the next virus hits us, the next pandemic hits us. We can't go back to having that just be a political response. So I just think this is really an open question right now, whether we will learn and really build a strong public health system, or whether the recriminations are just so harsh that everybody will run away from it.
Jason Helgerson 22:51
Yeah, and I guess my concern, my fear a little bit is that the pandemic has politicized, not just public health response, so like mass requirements, and stay-at-home orders, and all those kinds of things, but it's also politicized the clinical components and the clinical response to viruses. And we've had a long history in the United States of of anti-vax feeling, but I almost feel like this pandemic has exacerbated that and my worry is then that will ripple through to the healthcare system, and to the health of the public. And I'm just wondering what your thoughts are relative to that, the knock on effect to clinical care and people's views of clinical care and the advice they're getting from clinicians. Are you concerned that the politics of all of this is really going to fundamentally affect, do people trust their doctor? I mean, I'm just wondering what your thoughts are on that.
Governor Jim Doyle 24:00
I think there's no doubt. I mean, just take the vax before COVID, the anti-vax movement was a weird little thing that went on in certain communities, but nobody really objected to having their kids getting all the multiple vaccinations that are needed to go to school and so on. And you think of all of the horrible diseases that we've eliminated through vaccinations, and I think now, I wouldn't call it mainstream, but it's almost mainstream to be anti-vax. So, yeah, I think it's a big issue. The personalities of this, the politics of this are difficult to deal with, I think the big decision that was made by the Trump administration that was really bad on this was to turn it back, when Trump found out that this was really much more difficult than just it's going to be a way we're all going to be in church on Easter, then he just punted it to the states. And I think if we had had a really good, strong national response, that was sensible, that was medically related, I objected to some of the things Fauci did, not the scientific things he did, but going on Saturday Night Live, and he clearly seemed to me to be enjoying a public kind of public figure. And that's not what his position should be, you've got to really protect the sanctity of the science of all of this. And so I just think a lot of people made it worse. But I do think the really fundamental decision that you alluded to earlier in this discussion was sending it to the states where the governors were doing all these different things. It turned out to be deadly for a lot of people, if you were living in states where governors were just resisting it. Back in the middle of it, I looked up a couple of these states that were so proud that they were open for business like South Dakota. I remember comparing South Dakota with New Hampshire, because it's two states, roughly very small populations, largely ethnically white, in many ways, similar in the demographics, not similar in the politics, and the death rates were multiple times higher in South Dakota than they were in New Hampshire. So as you know, as everybody knows, this virus didn't care what state it was going over. So I hope the one basic thing we learned is, if this happens, again, you need a good, strong national response, you need an international response, but you certainly need a strong national response.
Jason Helgerson 26:45
All right. So Governor, a question has just come to mind that I'm now dying to ask you is, let's just say governor could be a Democrat, could be a Republican, could be from a Midwestern State, East Coast, West Coast, Southern comes to you and seeks your advice, they just got newly elected, what would be your advice to them in terms as they look forward and begin to embrace their role in health and health care looking forward to the year 2049 into the future and how they can best position their state for for success and protect the health and well being of their citizens? What should that new governor be focused on, that would really help position their state for having a strong healthcare system in 2049, or a really healthy population in that same year?
Governor Jim Doyle 27:44
Well, I don't know if many would take my advice on this, but the way I saw being governor is, if you're a governor of a state, you're not going to remake a national health system. This is how I saw it, it's really not up to you, you can talk about how health reform should happen on a national stage and so on, but the real role you have is to try to make sure the people of your state have access to health care. And so again, with your help, Jason, a lot of what we did was, well who are the people that don't have it? Under the Medicaid system, the so-called childless adults didn't have it. So how do we expand to people that didn't have children, but needed it? Then we found, particularly in the recession period of time, that a lot of people were out of work, and they didn't apply to Medicaid. So we were able to extend our basic Medicaid program, they had to pay, but they paid on a sliding scale. So I saw it as a matter of looking at what are the needs and how do you practically find the resources to meet those needs? Some governors get into these big political fights in Wisconsin, as I think you know, and of us, just gall you, we don't take the enhanced Medicaid money from Obamacare and it's just absurd. Even Missouri, South Dakota had a referendum, all these very conservative states at stake. And so why don't we, because the Republican members of our legislature who control think that it will make people dependent on the government, so for political reasons they're keeping people away from having health care. Again, I don't know if this is advice to governors, but I just think the role of a governor should be to try to get people covered. Interestingly, in Wisconsin, again, as you would know, but I was recently with Governor Tommy Thompson, who later went on to be the Secretary, and we've done a number of these things together now where we talk about it, but he started the Badger Care Program in Wisconsin. At that time it was really an important part of the Republican welfare reform, which was to expand Badger Care so people with higher incomes who are working have access to it. That was part of welfare reform. It was accepted widely by Republicans around the country. And he built a program that was very good. And when I came in, it was growing, and we expanded it dramatically, and moved it into other places. But the basic core was a Republican governor that had a Democratic legislature and our big expansion happened with a Democratic governor, and we had one house that was Republican, we needed Republican votes to do it. So I would encourage governors not to get into this partisan fight over it, and to really just be looking at what they can really do to help the people of their state. What you need to do, I think, we know this, I mean, it's pretty basic stuff, you really need to make sure you have healthy pregnancies and good birth, you need to make sure there's good health care in early childhood, that there's good, and all of the other things, all the social determinants as well as are much more important than the clinical part of medicine, but there's food and housing and good education and the things that really are going to determine what a person's lifelong health are. And you've got to work against the basic tobacco and other things that young people will be tempted by as they go along. And you want to really make sure that there's a good basic health care system in your state, which we've been blessed with in Wisconsin. Our basic health providers are very, very good in this state, and always have been.
Jason Helgerson 31:51
Well, great. So one final question for you, governor, and that is what role will governors play in health and health care in the year 2049? So do you see the role of the governor changing roughly 25 years into the future? Or do you see it roughly the same? Just looking at your successors in the future, what do you see their role being?
Governor Jim Doyle 32:20
They're going to have a very important role, I think one of the things we see as the federal nature of our country is very strong. And that we saw it for maybe for worse durning COVID, but the the demand for states to make their own decisions is a very, very powerful force in this country, and will continue to be. Our federalist system isn't going to go away in 25 years. You've had others who are much more visionary on this, but the data will be much more powerful. Some of the really fundamental issues that states are going to deal with, and these will be state issues, are how you deal with death. When you continue to spend the highest percentage of your healthcare spend on the last few years of life, it isn't very sustainable in the long term. We can see this now states are dealing differently with assisted suicide and other kinds of issues that are very difficult to talk about, but I think are really critical. Our technology means that and the scientific advancements that maybe they can get us to live to 110 or 120. But I guess the question is, what's that life like from 85 or 90 to 110? Those kinds of issues we have left to the states and I think will be really fundamental for governors in the future to be dealing with.
Jason Helgerson 34:06
Well, thank you, Governor. And that was Governor Doyle's vision for health in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe to us on Apple Music and Spotify and share this podcast with a friend. Thank you and see you next time.
