January Town Hall: Reimagining Healthcare from the Inside Out

So once again, welcome everybody. I am Dr. Cesaly Habert. I am a family practice doctor at Northern Virginia Family Practice. This is our town hall and we’re very excited to have you all here with us this evening. Tonight we are joined by Gary Jacobs, a healthcare advocate, entrepreneur, and what he calls a Zen lobbyist in Washington DC with over three decades of experience. Gary has helped shape national payer and government strategy for one of the largest value-based primary care organizations and advised top decision and policy makers on bipartisan solutions for reform-driven payment structures. That’s a lot. That’s a big mouthful. So hopefully he’ll tell us a little bit more about that.

Gary teaches the business of government relations at American University and is a certified yoga and meditation guide who leads meditation and mindfulness practices at conferences and seminars across the country. Gary is the newly published author of The Zen Lobbyist, Leading Healthcare Reform with Mindful Practices, a book that weaves together his professional experience, personal wellness practices, and even his own life-threatening health challenges, including a stroke and several hospitalizations that transformed how he leads and why he fights for change. Today, he combines presence with policy, bringing mindfulness, resilience, and clarity to our healthcare system with the mission to help reimagine healthcare from the inside out.

So, before we dive in, yeah, that’s fantastic. There’s the talk. Good night. No, but before we dive in, I do want to just mention that there are four things that we should know about Gary. Hopefully we’re going to talk about all these four things in some detail. Number one, he is redefining what it means to influence in Washington. And right now in this day and age, this is a very important lens to be looking through. He’s also the author of The Zen Lobbyist — I think we mentioned that — we’ll be talking about this quite a bit. Cultivating influence and compassion with clarity. Number three, he’s an educator and mentor shaping the next generation of advocates. And number four, I have the honor of being Gary’s primary care doctor and being a partner in his own personal healthcare journey.

So this is pretty exciting. We’ve never actually had one of our patients on our town hall and I’m just really excited to have this opportunity to do this and to be able to share this type of experience with people that mean a lot to me. And you’re one of those people, Gary. You mean a lot to me. And vice versa. Absolutely.

So the Zen Lobbyist — Gary, can’t wait to talk more about this — but as a side note, as an informal student of Zen myself, I am currently studying the works of Buddhist teacher and Soto Zen priest Suzuki Roshi and just this morning I was reading a passage and he said Zen is the practice of seeing things as it is and accepting things as it is and nurturing things as they grow. And it made me think of you and it made me think of this book, Gary. So what does it mean to you to reimagine lobbying through a Zen lens?

So Cesaly, the perspective people have of lobbying and quote unquote success in the field has really been about money and money defining influence. And like it or not, money provides access to lawmakers and it’s going to events where they’re hosting a fundraising event and you meet them one-on-one and then you develop a relationship. You kind of feel where they’re at. Are they going to be supportive, not supportive? Can they impact you in a good way or are they going to be a challenge all the way? This is kind of a general back and forth of lobbying. This is just sort of what traditional — but that’s been the traditional way I kind of viewed it.

And through the events of my life I kind of came back to Washington not as a young guy but as a mature adult, if you will, and I looked at relationships from the lens of empathy and compassion and was very grateful and full of gratitude for the ability to form these relationships, especially from an advocacy standpoint in trying to advance a position that I had. And the only way I could do that was being authentic, being real. And that required me to know exactly who I was. I mean, the narrative you think about who you are isn’t necessarily the true you, the essence of who you are. And you land up being caught up in that narrative. And the ego dominates and before you know it, you’re now something that can get upset, can be hurt, can be challenged and could not forgive. And I did not like those adjectives in the way that they would describe myself.

So I landed up understanding that if I knew who I really was and stripped away all the nonsense or accoutrements of whatever was me and learned who I really was inside, I could then be that person in my work or in my life in general. So my relationships are more profound to me because they have a genuine essence to them. And I wanted to apply that to lobbying because my god, no one — if you walk into an office and you’re watching X, Y, and Z news and there’s a bias about somebody and you go into a meeting with that person and you have that bias, well, you’re really not advancing your cause by thinking you can change that person’s mind.

So you really can only — if I talk to you about your parents or your family or your kids and we have connection on that human level, it’s a much more sane and longstanding way to develop a relationship. So I sought to do that and that required learning the practice of compassion, learning the practice of gratitude and finding myself embracing silence and listening much better.

So you said that you returned to Washington DC. You were here and then you left for a while, then you did some work and then when you returned to DC this is sort of when you came with a kind of a different lens, I would say. So yeah, I spent 25 years after graduating American University and getting my graduate work done. Oh so you did your undergrad there. Okay. Yeah. In South Florida. And if you’re going to be a healthcare entrepreneur in South Florida, you’re going to learn a lot about the good and the bad and the ugly of the business of healthcare. And I did. And through the book, I talk a lot about experience with FBI and people like that, because there was more fraudulent activity in that community than any place. I know they wrote the book on it, I think. I don’t know. It was pretty crazy.

Yeah. And then you had experiences, personal experiences, health experiences, that you describe in the book, and I hope I’m representing you correctly, but you describe as sort of being a turning point in sort of how am I going to live my life? How do I want to show up? And so can you tell us a little bit about those experiences and how that changed you?

So for everybody listening, anxiety and stress unchecked can lead to severe physiological and psychological consequences that people could tell you about. But until you go through an experience like this, oh my gosh, it’s life-changing and it can put you in a very, very bad place for a very long time. So I had experiences through stress as an entrepreneur who forgot to take care of himself, thinking he was but he really wasn’t — in what I eat, in how I sleep, in the exercise I do, and in everything that we think keeps you healthy. And the stress just overwhelmed me. And then there was a sentinel event that kind of triggered flight or fright and it didn’t go away. And as it stayed with me, I lived in a state of fear. And if you live in a state of fear, it’s almost like you can’t drive, you can’t have a sane conversation because you are stuck in the mud in that space and you cannot get out of it. And then the thing that medicine was doing in South Florida when I was going through that was giving you medicine to get out of that mud. And I knew that I had to learn on my own how to do that my way.

And I met a friend of mine who was the dean of a local university in Fort Lauderdale — Nova Southeastern. And he said to me, “Gary, I went through a very similar experience. And I started to use biofeedback as a therapeutic tool for me to understand how my body would react to stress in different ways.” So I said that sounds very interesting, very cool. Let me try that. Not knowing much about what biofeedback actually did, but it sounded cool. And it was much better than just living on medication. So I said okay, I want to do that. So that’s a whole other story we’ll get to.

Yeah. So basically that’s what started opening the door. It really sounds like you kind of hit a point where you were just living in a state of complete fear. And I think that when we’re in that state where we’re sort of surviving maybe, but we definitely aren’t living. And so it sounds like that’s when you started making some shifts at that point. Oh my gosh. Yes. Conscious decisions. Having a really supportive wife — and in my case, you happen to know my wife really well — by being the kind of person she is, she made it her business to figure out what was wrong with me and how we’re going to fix this.

So as this was evolving, I owned a home health company and in South Florida, home health was one of the triggering places for fraud and abuse in so many ways that we don’t want to talk about today. But the point of that — that’s a different type of conversation. Oh my gosh. Yeah, that is a whole thing. You were living in this. You were navigating, you were basically swimming in it, right? So here you are just being constantly triggered, continually. I can’t even imagine. And two neighbors were FBI fraud investigators in healthcare and that didn’t make it any easier because you just go out to wash your car or something and you’re dealing with people that were very nice guys but they were also looking at everything from a suspicious lens.

So the point of the story is that I go to San Diego to a home health conference. I’m now more functioning at least, which was very healthy for me. And at the conference I said, “Hey Stace, you know who just moved here? Deepak Chopra from Boston to open the Chopra Center for Well-being with David Simon. And I would love to go spend the weekend there.” So out of nowhere, we decided to do that, Cesaly. It was great. And Deepak was kind of new to teaching all of the things that he was educating us on. Kind of up and coming. How long ago was this? This was 1993. Okay. And he was just beginning his whole — he wrote his book Seven Spiritual Laws and a couple of other books but David invited him to San Diego so that they could really start using integrative medicine and different approaches to Ayurveda in healthcare in general and see what it would do.

So I had an extended weekend with Deepak, Stacy and I and four other people and I learned that the practice of yoga that I was doing to stretch for my marathon running and things like that was not just about physical asanas. It was really about a whole philosophy of life and a way of life. So if I could figure out how to incorporate many of the principles of yoga into my day-to-day existence, then I would be a much happier person and this whole time of fear would leave and I would understand it. So it actually worked for me and I came home, I went to my biofeedback therapist, I said I’m done. Thank you very much. I got it. And I never looked back. And that was 30 years ago now that I’ve been a daily meditator, a practitioner of mindful behavior, and it’ll get to why I wrote the book when we get there.

Yeah. So I mean, to think that this weekend was pivotal, right? You need an event in your life to kind of — like you as a patient, you can come in and you could tell me, Gary, you need to stop eating so much ice cream or whatever it might be. But I totally get it now when people say, “Oh, you need — when you hit bottom is when you can start going to the top again.” I wasn’t in a place of bottom, but I was so out of control of my own feelings and sensations and emotions and thoughts that I really didn’t know who I was anymore and I was getting lost in that. And then the fear, anxiety, depression kind of makes that worse.

Mental health is a broad category now that everybody knows somebody with challenges and it’s not just the big names you hear about in terms of depression or any of the disease states. But it’s really the day-to-day survival and living and how you cope, your coping mechanisms and how they work. To me, it was almost like — and you know this from the Zen work we’ve talked about — you almost need to begin again as a beginner in everything you do, in a beginner’s mind, every day. And start right and every breath, every moment, right? And every moment is the best moment because it’s happening right then and now. It’s the present and it’s a gift. And honestly, I never would have realized that until I meditated on a daily basis and on a regular basis. And people like Deepak were teaching me how I could take that meditation off of the mat, so to speak, in yoga, or leaving the mat and then living your life through that lens.

I believe that every day of my life is a gift. Every moment of my life is precious. And it’s the special moments that come together that create who you really can be and who you really are, to be your best version of yourself and applying that to anything you do, whether it’s being a dad, whether it’s being a grandpa or whether it’s being an employee or an employer. It made me better than I could have ever been before through this knowledge of who I was.

Yeah. I think we spend so much of our lives worrying about the future or regretting the past, right? Exactly. And you know, we get really caught up and we’re sort of — it’s just that moment. It’s that coming back to that moment as it is, is sort of where we need to come back to. And it’s not easy. So you had this great weekend and suddenly you started seeing things differently but I’m sure it wasn’t like now everything was easy, right? It’s just a culmination, it’s just a shift maybe in the practice. I mean that’s what I kind of look at this as — there’s no such thing as perfection, there’s just practice and there’s just meeting yourself who you are every day and being the best that you can.

So, it’s funny — I remember Stacy threw me a surprise 50th birthday party. I was teaching yoga on weekends in a museum, a little community museum in Coral Springs, Florida, which is south of Boca Raton and north of Fort Lauderdale. We were living there and the executive director of the museum said to me, “Gary, there’s a group of women who want to have a yoga session or a yoga party, if you will, would you mind teaching it on a Saturday night?” I go, “No, that’s a cool idea. I like that. Let me try that.” So as I come in, Stacy’s quiet as could be and we’re walking in and all these people are there on yoga mats and I’m making an entrance and I look around the room. I go, “Stace, that looks like Barry and that looks like Mark.” And she goes, “Surprise, honey. There it is.” And everybody came from all over.

And I’m in the teacher position in front of the class and I look at all these people in my life from my kids to my friends that I grew up with to everybody that I knew and I said, you know what, being 50 is the first time I think I have a concept of who I really am. And through that lens is when I really began to know how I reacted to things and why things were important and why they weren’t important. Things like forgiving are important not necessarily for the other person as much as it is for you, because if you’re the one carrying the burden of not forgiving then you’re the one suffering, not them necessarily.

If somebody walks by you down the street and says, “God, Gary, you look tired and you look like you gained weight.” Okay, fine. Pass it on. If I absorb that and I process it and I’m thinking about it during the day, is that going to upset me? Not anymore. Did it used to? Yeah. But it’s the little things like that that when you string them together into a lifestyle and then apply it to everything you do in your life, you can be the best version of who Cesaly is, who Gary is, and who everybody is. Yeah. Just if the world could look like that, we wouldn’t be fighting, we would be loving. And my first page is all about love and caring and loving kindness as a practice. And if people knew love more than war and hate, they’d be a lot better off. Sorry, there are lots of dogs around here. No, that’s fine. I love dogs.

So tell us about — we kind of alluded to this book. So what brought you to the point that you wanted to write a book about all this? Was it something that you came to on your own? Was it something that somebody said, “Hey Gary, you’ve had such an amazing life, you should write about this.” How did this — I was getting to that place where I had retired once and then I retired twice. Yeah. And I kind of was really bad at it. I was pouting around and I wasn’t feeling good about it. And I started to journal more and as a practice — journaling, not like a diary, but just when I had something to write about. So I kind of liked the way I was writing. So as I did that more and more, I said, “Well, I can have a message.”

And the message — Stacy and I used to go through — well, I learned primordial sound meditation from Deepak. I went to every course he had ever given. Traveled pretty much over the world working with him and people that he worked with and learned so much about these different meditation techniques to really get in touch with feelings, thoughts, emotions, sensations, and how to differentiate between real and unreal and manifesting this and that. And anyway, a lot of things like that I learned along the way. And the question always came up, how authentic could I be in my teaching and my practices? Authenticity was critical to me because I was, you know, a normal guy that grew up in a suburban New York environment and would people take me seriously if I was really doing this?

And as I kind of learned more and more and knew that this wasn’t like I’m Johnny come lately to the party, but that was 30 years of practice — and you know, when I met you it was like my first, as my doctor, you needed to know this was part of who I was and knowing that we embraced it a little bit together was even more rewarding for me in our relationship. But the point of the whole story is that the authenticity of these practices and then trying to teach them required at some point to put it down on paper, whether you’re teaching or whether you’re going to write. So I started writing more and more and then I said well what should I apply this to?

And I remember reading as a college student, Zen in the Art of Motorcycle Maintenance. Okay. And it’s a book back in the day. So if I was in college, you were probably not. And the point of the story is that the book had very little to do with motorcycle maintenance, but had a lot to do about a dad and a son traveling the country and experiencing the now, experiencing the moments of their lives together and talking about it. And I’ve done that with my sons, not with a motorcycle necessarily, but in trips and in things we’ve done together. And as a grandpa now I’m watching them do it with their kids and oh my god it’s like a full circle. So it’s really beautiful and it’s real and it’s genuine and I had to put it down on paper at some point.

So I did during COVID and I was able to work with a lot of people to really frame what I wanted to do, because the challenge was integrating the practices with work and normal life so that people didn’t think I was woo woo out there and I was some crazy guy. I mean, I had to put sanity into it. So I applied the lessons to lobbying, which is the craziest business in the world.

Yeah. Did you come up with that? I mean, did you just kind of come back to Washington and say, here I am, this is sort of my approach to life and now I’m going to see what this is like to be a lobbyist and try to incorporate. No, it didn’t work that way. Okay. Because you can’t really plan your life. It just happens, right? Things go. And I was working for a company and it was an insurance company that was getting into Medicare Advantage and the prescription drug programs under Part D. So Part C and Part D of Medicare were changing. As I was in DC working with CMS and what those changes were going to look like, I brought it to my company and I sold the idea that we should be in these businesses and we became the seventh largest Medicare Advantage plan and the third largest Part D drug program. And it really made a little company a very big company, a Fortune 500 company. And here I was now in corporate politics and I was the lobbyist for this Fortune 500 company.

And it was — part of the lessons are that any organization that is going to be regulated in any way, shape or form, whatever that might mean, needs somebody to advance their mission in DC. And why I started teaching at American University — A, I went there and B, I was on the board of my school. And C, there’s nowhere in the country where you really learn to lobby. You can go to every best school in the country, whether it be the top of the Ivies or out on the West Coast where I am right now — and being a grandpa, by the way — and no one teaches lobbying. You can’t go to school and learn how to be a lobbyist. Most lobbyists work for a member of Congress and then go to a lobbying firm on K Street or one of the law firms that have a lobbying shop. So I went to the dean and I said we should teach this. So I developed five modules and started teaching the business of government relations.

And at the same time, Cesaly, TikTok was starting to go through its issues. Okay. So everybody — it became relevant to everybody. Gosh, if TikTok needs lobbyists, it’s a viable industry. And then the kids at school said, “Oh my gosh, there’s money in this, huh?” I said, “If you are the lobbyist for TikTok and you own stock in TikTok, it’s a great opportunity for you.” So everybody needs to advance their advocacy and you need to learn how to really be a genuine person because if you’re a phony in this and try to fake it, you’ll get busted right away. And that’s really not what the change in Washington needs to be about. It needs to be real people doing real things.

Yeah. And you said in the book that compassion is influence. And that’s such a powerful reframing of what influence can mean in Washington. So what does compassion look like in a world that’s often driven by competition, urgency, and ego, essentially personal gain?

So three principles aligning there, right? So first, silence is strategy, which is a whole other thing. How does that make any sense? Because you can’t in the chaos of everyday life think clearly and evolve as a human being. So in silence, or in my world, meditation, I’m able to get away and escape from the day-to-day chaos that we all live in on a 24-hour news cycle. And I’m able to go down and do the work that has to be done to find out who you really can be and who you are.

Compassion is influence is just by being somebody that connects and builds bridges together with other people. And Cesaly, I have friends in Congress now that you see on CNN, Fox, MSNBC. I know people listening represent all of those places. But all I’m saying is that people at the end of the day are human. They have the same issues together — their parents, their kids, problems, concerns. And when we connect at that level with each other and we’re open to being vulnerable and sharing with each other, it becomes life-changing for them, for you, for everybody. And they become more honest and direct.

Chairmen of various committees in the House and Senate who deal with healthcare, Medicare and Medicaid issues that I deal with will say to me, “Gary, look, I grew up in blank blank wherever and I went to this university — could be a military, could be an Ivy League, could be a state school. How am I, as chairman of — I don’t know how I became chairman but I’m chairman of Energy and Commerce or Ways and Means or the Senate Finance Committee and I have jurisdiction over Medicare. I have jurisdiction over tax. I have jurisdiction over oil. How am I supposed to know all those issues? I can’t. And I never was taught all of those. But if I find somebody like you who is at least real and I can talk to as a friend, knowing you have a position you’re advocating for, but stripping down to the basics of let’s just talk and the basics of humanity, just the things that we have in common with everyone.”

Right. I mean, just yeah. And you can just sort of — it’s just a place of realness. Maybe it’s just a place that, you know, just like with all of the posturing and the optics and all the stuff that happens in Washington, I mean it really is unique to be able to connect if that person or group is willing to do that. But I mean you have to be the one to present as vulnerable yourself in order to allow somebody to — and if we don’t do this as citizens of this country now and be courageous, be courageous and bold, as advocates, things aren’t going to get better. And I want things to be the best they can be.

Yeah. So I mean, it’s really interesting, Gary, when you talk about stillness is strategy, compassion is influence, and just the vulnerability. I mean, as a primary care doctor, you’re talking about going in and having a meeting with somebody in Congress, and you were actually describing what it feels like to me a lot of times to go into an exam room with a patient. A lot of times, part of the teachings — so I don’t know if you know, I did a fellowship in contemplative medicine. And I don’t know how many people know about that, but I spent a year working with the New York Zen Center and just sort of creating a different lens maybe to look at what we’re doing in healthcare. And so having that pause before I see a patient, that stillness is really important because that groundedness, that beginner’s mind is really, really important because it just allows you to be more open and create a safe space of vulnerability. Because I think when you go in to see a physician, you’re in a state of vulnerability, right? I mean, it’s scary to be sick or not know what’s going on with you, and then to create a safe space for that, I think, is important.

And so I see that as the compassionate space. You know, if people aren’t vulnerable with each other they’re not going to share — I’m not looking to know everything about everybody, that’s not — it’s more about how do you — people ask me how do you stay so calm and peaceful even in the middle of all this chaos all around? And I go, it’s not really that difficult if you know who and what you react to. The idea of feelings, emotions, sensations, and thoughts are things that evolve within us and then they leave. If we get stuck on any one of them at any time, then we kind of get caught up in this kind of superficial reality of who our ego thinks we are, but we’re really not.

And the loving nature of every human being, thinking through their heart and not necessarily just thinking through their mind whose job is to just create thought, but thinking about their heart whose job is to create love — and also to pump blood I guess, in all the things you know better than me. But just that little change when you go from my mind is overthinking to my heart is wanting me to love, I mean that’s a big change. Yeah. Just returning to the moment, returning to that stillness, I think is an important thing to remember.

So just sort of building on that — I mean, you’ve obviously spent your whole life in healthcare and I think where we’ve talked about the importance of primary care and the role that that plays. So what in your vision or your reimagined world of healthcare, what role does primary care play?

It’s the key part of the whole system. Everybody listening, you should recognize that you can’t navigate healthcare on your own. It’s much too complex. And I could chapter and verse tell you about the dynamics behind how Obamacare happened. What are the secret little things that happen behind the scenes? What are the things that make it work every day? But the truth of the matter is that to access healthcare in this country, it has to be through primary care as the entry point. And primary care in my world can’t be just the primary care physician. It’s a primary care team led by a primary care physician. And primary care doctors really need to be proud and again be courageous and bold to be primary care docs and to own the relationship with the patient and then develop the relationships with the referral doctors out there so that somebody knows they have somebody in their court that they’re working with.

And like in our relationship, Cesaly, we’ve worked with acupuncture, we’ve worked with various kinds of therapies because A, I’m inquisitive and B, so are you. But these teams should be primary care led and they should include nutritionists. They should include yoga therapists, which is very important to me. They should include personal trainers because you need to build your muscle and strength as you get older. Don’t think that you’re 70 and it’s over and you shouldn’t keep doing this. Go to the gym and work with a trainer. I mean, my wife and I do. And I have to reinvent my own health because I know that it’s a critical thing to do.

But these teams don’t work in fee-for-service healthcare. And for everybody listening, fee-for-service has been the dominant form of payment, but it’s transactional to me. And transactional means you could try to develop a relationship with a PCP like Dr. Habert, but you don’t have a lot of time to do that. So sometimes you just say, “Okay, I’ll go to urgent care because I have a headache that’s not going away or I need a shot or whatever it might be.”

So I’m proposing that every American has a primary care-led team. That team is paid what I would call a population health payment. So it’s sort of like a monthly fee the primary care team has to help finance the cost of all the people they need to put in this team and their overhead and their own so they have money to themselves, and that they refer you out to specialists who get paid on the episode of care that you’re going through. So if you had a broken arm or you need a hip replacement, it’s a pre-negotiated amount that Dr. Habert is referring me to Dr. Jones and Smith and they’re getting a pre-negotiated amount for the hip replacement that I got. And then the rehab gets the same kind of relationship, all monitored and owned by the primary care doctor.

And then when that is all over, at the end of the year there’s kind of a look back at what the costs were in the previous year and what the cost comes out to be through this management relationship. And if the cost is less, which it will be through efficient use of resources, that money is split between the payer and the provider. So the same dollars get spent more efficiently. There’s somebody in your corner watching how they’re spent. And at the end of the day, you can’t do like national health insurance or Medicare for all without reforming the cost of services, whether it’s primary care, specialty care, or hospital care. It’s really hospital and rehabilitation and specialists that eat up more dollars than primary care will ever see. Primary care literally is maybe 5% of the overall dollar spent on healthcare. It’s crazy. But New York is looking at now a law to bring it to 15%, which is a good move forward.

But it shouldn’t be laws telling us how to do that. It should be more or less a mechanism that says the patient should be satisfied and have a measurement and the quality should be measured and if there are savings based on that quality and that patient satisfaction, there’s a distribution of those savings to the providers who provided it, led by our primary care doctors. And primary care doctors shouldn’t be the low end of the spectrum in dollars. They should be making the most because they would have the most responsibility in this model. So it’s not like Medicare for all, everybody. That would be wrong because it’s only a payment mechanism. It should be primary care for all, which really is about primary care-led healthcare, and specialists are at the beck and call of the primary care physicians. And hospitalists — there are so many things that have changed and there are so many things to do with dollars that have caused those changes. But when you strip it all away, we’re humans wanting humans to take care of us. And we don’t want transactions that are just going to leave us alone again.

Oh, we have a little friend that’s coming to visit. That would be my little grandson coming in and out. Oh. Oh, that’s — thank you, Noah. Yeah. Yeah. And that was one of our dogs.

I mean, as a primary care doctor, I think I’ve — this is something I’ve always known, that I wanted to go into primary care. I sort of see myself, and I’ve explained this to people, as sort of the project manager of their health, right? And it’s not so much — you said beck and call. I know and I suppose you could think of it that way. I like to think of it as I work with relationships. I develop relationships with other specialists and I really try to just create connections and meaningful relationships and to help further and advance somebody’s health. So that’s just, you know, and I think as a primary care doctor, that’s really what we do. I mean, we really try to — I sometimes explain it as making sure everybody’s playing nicely in the sandbox together, right? Nobody’s throwing sand in anybody else’s face and basically we’re all human beings and we’re trying to support the health of our patient.

And when you refer me to anybody, I always say to them, whatever we’re doing, please make sure that Dr. Habert has the same notes and that you make sure you get everything back to her ASAP. I’m looking for you to tell me the information, not necessarily what the specialist is telling me. Yeah. I mean, I need the specialist. I say, you know, let’s phone a friend. And I like having lots of different lenses to look through, but I think also just having that connected relationship with your primary care doctor who can sort of help kind of sift through the information and also give you a safe space to process everything, I think, is important too.

And I have to say that just working at Northern Virginia Family Practice — as most people know, this is a membership model, concierge medicine — I feel very grateful. There’s your other word there. The gratitude is renewal. I’m very grateful for having the opportunity to be able to develop these types of relationships with my patients here. And being direct and honest with each other.

Yeah. You know, like I felt part of my role in this as a patient was helping you become the best concierge or direct primary care doctor you could be. And it was new to all of us when you were starting. I remember, and I love what our relationship has translated into in real terms. I hope everybody else feels that too because they shouldn’t be shy, right? They should be direct. They should be honest. They should know why they’re coming and not forget when they come to see you, what they should have — their little list. And you can even use ChatGPT at times if you want, because everybody else seems to, just to know what are the questions I should ask my doctor when I come to visit, right? Just to know.

Yeah. So there’s actually a really long message in the chat. And this is actually — I don’t know if you’ve ever met Dr. Sullivan. He’s one of the doctors here at Northern Virginia Family Practice. He writes, “Thank you so much for your wonderful presentation and for sharing your authentic story, Dr. Jacobs. This is a long one, but I would appreciate your generous analysis. I have read most of the great American healthcare plan.” And he says, “My bipartisan loving questions given your experience as a patient and an advocate are the following. Number one, lower drug prices, lower insurance premiums, ensuring companies are serving patients’ best interests, and maximizing price transparency sound beneficial to our patients and to our healthcare delivery. Whether or not this is true that the above plan can accomplish these points, what as patients and medical professionals should we do to ensure that this does? We need this desperately.”

That’s a really good call out, Dr. Sullivan. Yeah. We need transparency in our drug pricing. It shouldn’t be as political as it is, but it is political. When we were negotiating the Affordable Care Act early on, they were really smart at pharma and they made a deal that looked like they were giving a lot when they really weren’t. But once they did that deal, President Obama said, “Okay, we’re done with that.” So you know what you have going forward. Was that right or wrong? I don’t know. But it kind of locked them in for the Affordable Care Act days that the government wouldn’t deal directly with the pharma companies.

Other issues you raised — in that transparency, Mark Cuban has now an Amazon-type drug business and he is saying he’s in the business not necessarily to make a lot of money out of it, but knowing Mark Cuban a little bit, it’s hard to imagine that there’s not a lot of money involved in this. But the point of the story is he said he’s going to be incredibly transparent with where all the money goes in the pharmaceutical world. Because you know that there’s something called PBMs, which are pharmacy benefit managers, and both Republicans and Democrats are calling out middlemen on every aspect of healthcare now.

So let’s start with that and then I want to talk about the insurance companies next. So PBMs is the best black box I think we’ve ever seen. I don’t want to say too negative because it’s just been the way it’s been. There are these insurance companies and they contract with PBMs to manage the relationship between the manufacturers of the drugs and how they get to the stores that people are able to buy them and what their benefit plans look like. There are a lot of people making nickels and dimes, which lands up to be millions and millions of dollars in the middle of that drug spend.

What President Biden tried to do is say, “We’re going to take 10 drugs to start and we’re going to negotiate directly on those 10.” And President Trump being President Trump — and you’ll never know if I’m voting D or R on anything because I’m looking at people, I’m looking at how things happen — but what President Trump has called out is why have only 10 drugs? Let’s do everything. So let’s do most favored nation status. So if Ireland is paying for Lipitor 50% below what we’re getting in the United States, how does that make any sense when we’re paying for the medication and the people in Ireland are getting it at such a lower price? So he’s calling that out, which — he’s got the audacity, the whatever the right word is, to actually try to pull this off. And I think he might be able to. That’s a beginning point. That’s a really good start, I think, to reforming healthcare in a broader way.

And Republicans really need to think this through. He’s laid out something now that says money should go directly to the patient. So you have Medicare Advantage. I don’t know if you take many Medicare Advantage plans in your practice anymore, but the truth is that more people are now in Medicare Advantage on Medicare than there are not. So 52% of all Medicare beneficiaries are in MA plans. There was a little lowering of that this past year because of all the bad press MA plans got, but it was done as a competitive model to Medicare as we know it, which I have no problem with. And I think that’s a good thing. But they overpaid on purpose to create a competitive marketplace so that you’d get better benefits in a Medicare Advantage plan, but you had to use what the insurance company told you. And you had that nasty thing called prior authorization. Oh yes. Which every one of you have dealt with. I know Cesaly and I have dealt with, but it’s out there. It’s something to be very, very aware of.

The point being in all this is that what President Trump is now saying is take the money that I’m overpaying to the MA plans and pay directly from Medicare to the patients. Let the patients put the money into health savings accounts and let them buy the best plans that they can buy for themselves. The bad thing is — oh, Gary, you muted somehow. Got a little crazy. Most of the people listening probably aren’t the best consumers of healthcare buying out there and we need a lot of transparency to make that work. So hospital pricing needs to be very transparent, specialist pricing needs to be transparent, procedures need to be transparent, and primary care — you kind of know what you’re getting. So you should really figure that out. But I think that should be a population kind of health payment going forward.

Yeah. But once you put that all together — remember one last thing, says, be quiet. Oh, yeah. We’re at 8 o’clock, but I think we could probably go over a little bit if we wanted to. But yeah. Insurance companies are pass-through entities. Usually they have a mandatory what’s called medical loss ratio. 85% of the dollars have to go for health spend. That can be very manipulated, by the way. But that means only 15% is what the insurance companies are working off of. But it’s a large game of numbers. So the higher the number of people that enroll, the more money that 15% — and that maybe 3 to 5% is profit — makes. But they’re pass-through and the insurance companies, unless they get doctors, specialists, and hospitals to bend the cost curve as we talked about before a little bit, and the prices don’t go down or prices aren’t brought in a bit better, then insurance companies or Medicare for all would just keep paying those same high prices. So we wouldn’t really affect the overall cost of healthcare in the country, which I think would be the biggest mistake we can make as a nation.

So if you want competition to work you have to have informed people that are buying. They have to be informed. So we need as a government to have an educational process so that people really learn how to buy healthcare and what it looks like. And then we need to give them choices. I wouldn’t want Medicaid, which are lower income folks, stuck in a Medicaid plan when they have a health savings account and a high deductible health plan, because they really might not have enough money in their HSA to pay the cost of the co-pays in the high deductible plan and they really won’t know what they’re getting into. So that one has to be really worked on and Medicaid has to be adjusted. So there’s a lot — we can talk for hours on these kinds of things.

Yeah. And Peggy’s asking — you’re talking about Medicare here. She says she’s fortunate to have great healthcare that’s affordable through work, but she’s approaching Medicare age. What should be my number one priority when I have to switch over in a year from now?

Oh, Peggy, let me tell you, I did that this past year. You did. I know. Yeah. And just to let you know, your last year of income, which is generally going to be your high yield income, determines what your Part B costs are. I’m paying $700 Part B a month out of my Social Security. And my wife’s like $650. It’s a lot more than I ever imagined, and it was more than my private insurance. Luckily, we can afford all these kinds of costs, but the truth is you don’t really know what you’re getting into with Medicare until you’re there. So if you’re getting there in a year, start doing your due diligence, start doing your homework, look at does Medicare Advantage work for you. In Northern Virginia, there’s not a lot of options and choices in that regard, but look at all of your options. Find somebody who can navigate you through those choices because it’s difficult. And are there companies or who can you hire somebody to help you just make these decisions? I don’t even know. But a lot of times patients will ask me and I’m probably the last person you should be asking about this. I deliver the care and that’s about it. No, I get it. It’s really difficult. It’s a lot. Yeah.

I mean, people ask me and I’ve been doing this for what, 40-ish years of working in the space. And when it came to me making decisions, I don’t know if I still made the best decisions, but they are what they are and I’ll figure them out. Yeah. But it’s hard stuff. Yeah.

So one — I think we’ll do one last question from Dr. Sullivan. And he says, what can be done to ensure that the patient-physician relationship is protected and advanced, which to him is the most essential aspect of any and all healthcare policy initiatives?

I agree 100% and you all have to — in the face of transparency, the reality is primary care doctors are getting hurt while specialists are winning, if you will. And in the AMA there are a lot of dynamics in politics behind the scenes that make up some of the committees that create the usual and customary cost that are divvied up in the overall Medicare fee schedule. The Medicare fee schedule is a really big determinant of overall payment to doctors in the country. And even if you’re on a commercial plan, the Medicare fee schedule is important because it’s a percentage of that fee schedule that the insurance companies are generally paying the providers.

So the dynamic — Congress is inept in my opinion to make decisions on should a physician who is doing surgery get paid more for this procedure than a primary care doc that’s doing X, Y, and Z. That’s a silly thing to ask Congress to do. So the Chevron rule last year — nothing new with Chevron company, but the idea that if you’re going to delegate authority, if Congress is going to delegate authority to administrative agencies and they’re going to make the decisions that Congress historically had made, who’s got the liability there and how do you fix that? So there are questions and concerns that really need to be addressed and I think this is kind of where we are right now. We really have a lot of serious questions to get the right answers and own and take control back of what’s been wrong for a long time and fix it before the whole system goes broke and we don’t really have the money to fund the cost going forward.

It’s not one thing. It’s multiple things interacting with each other. Congress people aren’t good and bad. They’re just people like you and me and us. And they need to be taught just like everybody else needs to be taught. The audacity and the courageous approach to curiosity, which is what RFK Jr., whether you love him or hate him, said he’d bring to the role. I’m dumbfounded by some of the actions that have happened, but I appreciate the role of being curious and investigatory. I think Dr. Oz in his role is a winner. He’s a really smart doc. He has made some mistakes in his past, I think, but that’s his stuff to deal with. But I’ve met him now in this role three or four times and I’m encouraged that he is the wisest of everybody there right now and somebody that will be listened to.

Yeah. So well, I think we’re wrapping up. We’re just kind of getting going is sort of the thing. But unfortunately — well, we could do it again when you want. I know. We could do it again. It’s only five o’clock where I am. I know. Exactly. You’re three hours behind us. But yeah, no, I think we’re just getting going on some of this Medicare stuff. I think there are a lot of questions.

David brings up — if you turn 65 next year and become eligible for Medicare and continue with your employer healthcare, I think he’s responding to Peggy — it says you can defer Medicare until you retire. That’s yes, you do, David. Good. Yeah. But here’s the challenge there, and I lived through this. You have to document that you had comparable insurance to what Medicare would have been. So your employer has to fill out forms. So if you leave your employer and go to Medicare, be leaving on good terms because they have to fill out a lot of paperwork. Otherwise, you’re penalized personally on Part D and Part C and B and A. So be careful of that.

But you have a lot to think about in these Medicare choices and preparing. If you have a financial planner, they should be involved in this decision as well because the amount of money you made in 62, 63, 64, I’m guessing, is a higher end of your earnings and that’s going to be reflected in your Part B cost. I mean, it’s never going to make sense to go to COBRA and stay on COBRA for 18 months after you leave your work because that’s just astronomical. But you’ve got to get Medicare right if you’re going to play. And unless you find a Medicare Advantage plan that you call home and you’re happy with it and your PCP is part of it and you love it, to me, you’ve got to go to a Medicare supplement plan. And the Medicare supplement plan is either G, which if you can afford it is the right way to go — you pay like $370 and then everything else is taken by the Part B plan. So you have a lot of decisions like that. Maybe we should just do a session on this someday.

I think I hear a spin-off. Well, my kids have always told me this is something America doesn’t understand and they really need to. I agree. And it’s something that even as a primary care doctor, I don’t understand either. And I’d like to be able to — well, maybe we should do it out of the practice. We could just have a little like we used to have in some of our primary care offices, insurance people that would actually give advice. Yeah. Well, so usually there’s a link there.

All right. Well, I think we’re going to wrap up here and it sounds like we’re definitely going to have a part two and a part three for kind of spinning off all these Medicare conversations. But I just want to thank you and also celebrate your book, which I absolutely adored. And I just think that you really do take a unique approach and a very human approach to Washington and to change. And I really appreciate all of the efforts that you’ve made, and also I have to honor the changes you’ve made in yourself to bring you to where you are in this space. So anyway, thank you so much, Gary, and thank you everyone for sticking with us. I know that we went over but this is a lot of information in this conversation and hopefully we’ll be able to talk about it some more at a later time. So everyone have a good evening and we’ll see you later. Bye-bye. Thanks. Be well. Bye-bye. Bye-bye. You too.