Pretend You Have Millions to Fix Health Care: What Would You Do? A Doctor Gives His Answer

Margaret Flinter (00:00)
Recorded on location at Aspen Ideas Health in Aspen, Colorado.

Mark Masselli (00:12)
Our guest is the President of the Commonwealth Fund, which has a strong focus on health equity and resources
to support its version for everyone in America.

Dr. Joseph R. Betancourt (00:22)
We also see some troubling signs. in fact, we see that vaccination rates have dropped, childhood vaccination
rates have dropped in every single state since 2019. And infant mortality has increased in 20 states.

Margaret (00:35)
Dr. Joseph Bettencourt is nearly three years, into his role leading the fund. He has some important insights at
this pivotal moment in our country as we think about how to provide and how to pay for health services.

Dr. Betancourt (00:48)
I think we've reached a tipping point. You know, Americans across the country, are having incredible difficulty
accessing primary care. Yeah. And providers are as frustrated as patients. So we have a unique opportunity, I
think, to, to leverage that frustration to some action.

Margaret (01:04)
This is Conversations on Healthcare.

Mark (01:17)
Well, Dr. Betten Bettencourt, welcome to Conversations on Healthcare.

Dr. Betancourt (01:19)
Thank you so much. Appreciate you having me and look forward to the conversation.

Mark (01:22)
And we are here at Aspen Ideas Health and, gotta say thank you for the Commonwealth Fund support of this
really important conversation that goes on over the next couple of days. Thank you. Really appreciate it.

Dr. Betancourt (01:34)
Certainly.

Mark (01:34)
And you know, we had the opportunity to have Karen Davis and Dr. Blumenthal on the show. We're really
familiar with the Commonwealth Fund. I'm not sure everybody in the country they should be. And I'm
wondering if you might share some of your mission, vision, and values, of the fund.

Dr. Betancourt (01:48)
Absolutely. Well, you know, Karen and David are, mentors, icons, and friends. So it's an honor to be invited to
continue that legacy of representation here at Aspen. So the Commonwealth Fund was established in 1918, and
it's important to call out that it was established by a woman, Anna Harti. Right. Harti family, was lucky enough
to, be very generous with the resources that they had, acquired through investments in Standard Oil. And
through incredible generosity of, Ana Harkness, $10 million was leveraged to start the Commonwealth Fund.
Commonwealth Fund in its early days, with its focus on doing well for the common good. Funded some
incredible work. The first public health departments. That's right. First rural hospitals that led to the Hill Burton
Act. the first advanced practice practitioner programs. we've done, work in our early days as well on the first
palliative care service. really incredibly innovative work. First medical schools in, in urban areas. So the list
goes on and on. In the last 25 years, it's been a pivot more to help policy. And our mission is affordable, high-
quality healthcare for everyone. Yeah. We're part, think, tank, part do tank where we provide grants to advance,
improving coverage, improving care, addressing healthcare costs, of course, making sure we leave no one
behind. So improving equity. Yeah. and we have some international learning and exchange that's part of our
portfolio of work. So, it's an exciting time. Certainly I'm thrilled, to be part of such a, I think, well-regarded
institution that is provided in a nonpartisan way, but in a very well-respected way, evidence to shape policy
most recently, some of the evidence that helped lead to the Affordable Care Act. Yeah. So here we are in
another time where we're trying to raise our voice and, and bring our science to bear, in a time where we're,
facing some pretty challenging decisions around coverage, care costs, and equity.

Mark (03:37)
Yeah. I don't, I know that list is long. I think child guidance, I would add to the…

Dr. Betancourt (03:40)
Certainly

Mark (03:40)
…to the area that you really were a seminal, leader in the field.

Dr. Betancourt (03:45)
Yep. Oh, yeah. I'm giving it short shrift. I mean, it's, more than a hundred years of, I think trying to really make
a difference for all Americans. And also, trying to share and, and learn from international partners. I think it's,
it's really time that we have that humility to understand that we don't have it all worked out. I think many, many
Americans understand that we have a, a lot to do, and there are ways in which we can learn from other places.
And so, you know, that's an important part of our work.

Margaret (04:11)
Well, we really, appreciate the history that you shared, and we'd like to honor our ancestors and the founding of
organizations and know that that legacy lives on. So, thank you. And you've just released your scorecard on
state health system performance. And this is an important contribution, I think that the fund makes. We'd love
for you to maybe tell us a little bit about the report itself. How long have you been doing it? What's the goal?
And of course, what are the findings that you're seeing during this important time?

Dr. Betancourt (04:38)
Yeah. So I've inherited a, just a wonderful team that creates a series of report cards and scorecards that do
everything from compare the US to international partners to rank all 50 states on things like quality and
outcomes and access equity, scorecards, women's health scorecards. So really incredible work. And I think
important. we have just released our state scorecard, which ranks all 50 states on a series of, measures public
data, in three areas, as I mentioned, previously looking at outcomes, looking at access and looking at quality.
And, I think what we see is more of the same, as it relates to the states that are high performing and low
performing. But let me just take a step back and say big picture. We have, really demarcated unprecedented
healthcare coverage, insurance gains, unprecedented. Right. 93 to 94% amazing of Americans, with insurance.
We see that in our state scorecard, incredibly important. despite that, we also see some troubling signs. in fact,
we see that vaccination rates have dropped, childhood vaccination rates have dropped in every single state since
2019. And infant mortality has increased in 20 states. So while we have historic coverage gains and people able
to get the care they need, in much better ways and more than in the past, we also have these troubling signs that
I think are even more challenging given some of the decisions, that are being made. Now, Washington, I'll end
just by saying that, we year after year can identify the critical success factors between states that are high
performing and low performing. It's investment in, in coverage. Massachusetts routinely, number one, has
invested in universal coverage. It's greater investment in the social drivers of health. and certainly I think we're
all trying to do more by way of primary care investment. And the states that end up on the lower side, clearly
demonstrate that not only federal policy matters, but state policy matters. Right. That's why we see those
differences.

Mark (06:39)
And, and there's some, nuance in that. You have a Mississippi, which might be low, but scores well on
investment in primary care. Right. I mean, it's, it’s a nuanced report, which I find interesting. Maybe just pulling
the thread on the immunization side, there are seven, I guess, recommended doses for children. 75% of the
country or the states, ha have them all. But it, you were trying to pull the thread on why, what's the reason it
wasn't all about misinformation, was it? What, what, what were some of the other factors?

Dr. Betancourt (07:07)
Yeah. Well, I mean, I think misinformation certainly plays a role. There's no doubt that the pandemic, and, and
everything that transpired around COVID vaccinations and mandates in closing schools and, and that entire, I
think, set of, situations that we faced, it did, it did create, likely greater hesitancy among people, asking more
questions. I think that we also understand that during that time, also, in addition to, the concerns that people had,
there was some misinformation that was put forth. accessibility and availability, I think, be, become an issue as
well. But the end of the day, when we think about the, the biggest and most impactful, public health innovations
of our history, vaccinations is top three along with, with sanitation and antibiotics. So, you know, we are in

favor, again, of providing evidence in science. And certainly I, as a primary care doctor, wanna make sure that
the vaccines that I'm recommending to my patients are safe. so, you know, having that discernment is something
that we welcome. By the same token, many, many, many of these vaccines have been tested over and over
again, and have been shown to save lives in some estimates, half a billion lives across the globe. So, this is an
important time for us to really bring that science forward.

Mark (08:24)
I'm Glad you man mentioned sewage. My dad was a water chemist, always reminded me that the big changes in
life expectancy happened, happened with an onset of, indoor plumbing.

Margaret (08:34)
Of course we're from the state that put fluoride in the water for first time too, so…

Dr. Betancourt (08:37)
Well, no, that's, that's, we could talk a lot about what's ally important. I mean, I think I'm doing a panel
tomorrow on, on reimagining public health. Public health doesn't, I mean, that's right. People on the ground,
they don't understand the incredible public health, interventions that are happening around them that, that they
don't see here. And feel, because we don't constantly tout that Sanitation's a base one, we take a lot of things for
granted, clean water, I mean, the list goes on. but major public health interventions.

Mark (09:02)
Let me ask an unfair question.

Dr. Betancourt (09:04)
Yep.

Mark (09:04)
Because you're just going through your first change of administration, but over the time, the Commonwealth has
always dealt with administrations that come in and make changes. And that just happens. That's the nature of the
reality. What do you do internally, in terms of your planning process? 'Cause you probably have a game plan
that arches over all of these. Yep. but at the same time, there's some tactical, decisions to make. Certainly, you
are a leader in the field. How are, how are you thinking about…

Dr. Betancourt (09:32)
Yep. no doubt. it's preparation, preparation, preparation. We began, you know, well before the election, you
know, deep into, you know, I'd say early, shall I say, but many, many, many months ago, into 2024, engaging,
because as nonpartisan, our goal is engagement, engaging, individuals who are going to be involved in either
administration with the notion that, engagement is something we want. we did want to get perspectives about
what the different ideas were around health policy on both sides, and really having a game plan for, both sides
and how they might bring forward health policy. Yep. And so that preparation really helped us. We understood
that things like work requirements and Medicaid were absolutely coming. we understood that on the bride side,
there was an interest in primary care. Right. And an interest in prevention. so that preparation really helped us,
and we have, built trusting relationships with individuals who have connections and are, in many cases part of
the administration Sure. And wanna add value to their decisions. Sure. So I think that that's…

Margaret (10:41)
Find that seam of commonality.

Dr. Betancourt (10:43)
That's right.

Margaret (10:43)
Good for you.

Dr. Betancourt (10:44)
Yeah. I mean, our goal is proving the healthy American people agnostic, to which political party's doing it. Yep.
But steadfast in our mission and vision and values to, to provide that, evidence that's needed to make sure that,
that we are committed to the health of all American people.

Margaret (10:59)
And part of that mission and vision and values is you need data. Yep. And you note that in the scorecard, that
there's some threats to public data. And that data is part of what helps us to look at health system performance.
And while I could take an educated guess at what kind of data might be missing or difficult to obtain, we'd like
to hear it from you.

Dr. Betancourt (11:18)
Yeah. I mean, there's a couple of big data sets, particularly outta the CDC, you know, series of data sets that
really provide key information on public health, on health outcomes, on hospital outcomes, and a big one on
health equity. You know, certainly we understand, and our commitment, the Commonwealth Fund, is to make
sure everyone, no matter who they are, where they're from, how much money they make gets the best we have
to offer, and we leave no one behind. Right. sadly, what we've seen is a lot of the data that's been stripped away
prevents us from really being able to assess the national landscape, find out where the gaps are, and think about,
think about where interventions might be. Right. So this is a major challenge, and we're working with partners
like Academy Health to figure out, do we, is there opportunities to stand up, data sets, lift up data sets, try to
advocate for the preservation of data sets. But, you know, we, we, we cannot navigate without information.
That's right. and so clearly data is important. And, we lament any efforts to pull data back that prevents us from
monitoring the health of the American people.

Margaret (12:20)
I think we've seen the same thing in the community health center system, 30 million patients, the Uniform
Dataset report, which had ample data on all the characteristics, characteristics that you're speaking of, being
pulled back for a while. We're hoping that that comes back, because that's very important data for you Totally.
As well, given the focus of the patient Population.

Dr. Betancourt (12:38)
Yeah. And it's data. And that data needs to be, taken care of by people. Right. So the reduction in forces as well,
and HHS are concerning. so there's a lot of things that are, that are concerning around our ability to, again, to
monitor and improve the, the healthy the American people. And, but the data one is, is certainly one that's really
critical to us as we play, we think we play an important role here.

Mark (12:56)
And it's so important to underscore, you're looking at everyone in the country.

Dr. Betancourt (12:59)
No doubt.

Mark (13:00)
There's no red states, no blue states, every state…

Dr. Betancourt (13:02)
No doubt

Mark (13:02)
…is what you're looking at. And talk a little bit about the blueprint, for health equity and when was it published,
and what do you think the timeline will be for implementation?

Dr. Betancourt (13:13)
Yeah. I mean, you know, we, we began to talk about this notion that really, health and it's evolved. I'll just say
it's evolved because sadly what we see is there's been a weaponization of even the simple term health equity.
Right. And a co-opting of that narrative. I spent my career doing work, on health equity in red and blue states.
And ultimately, what I've been able to do is I engage with people in, of all different political persuasions, is to
say, that we collectively care about doing exactly what I mentioned previously, making sure that any individual
who enters our hospital, no matter who they're, where they're from, gets evidence-based clinical guidelines. And
the best care, this notion of an equity blueprint is one that simply says we need to, number one, have good data
to identify where gaps are. Number two, we need to take action to fill those gaps, and monitor our progress.
Strategic planning, measurement, continued quality improvement intervention is essential. And we never for
once said, this is just about black people, or brown people, or those people, or those people. It's about all people.
And that's, that's the fabric of our nation. So this blueprint, I think, is, as we evolve it now, we're trying to be
more precise with what we mean when we talk about health equity. We think that's really, really critical. And

give examples of differences or disparities that impact people in rural settings. Right. That impact women,
people with disabilities, people who have low socioeconomic status, just to kind of, I think, reclaim that
narrative and, and provide that precision and clarity.

Mark (14:42)
Well, I wanna pick up on the regional thought because it's been clearer in the last couple of months as we've had
the conversation about Medicaid. there have been nice reports about every congressional district and the level of
Medicaid recipients in them. And you can see, it's, it knows no boundaries, right? Yes. and I think it's getting
back to this issue of, lies, damn lies and statistics. We want the data to really unite us not to divide us.

Dr. Betancourt (15:09)
That's right. I mean, it's paradoxical in many cases. I mean, some of the, you know, some regions that are the
reddest, you know, in many cases have the most Medicaid recipients. that's right. And so this doesn't just track,
by blue or red. And, and we want the best for all. So ultimately, I think we're trying to provide the evidence
around if, if, and how you change Medicaid, you know, these are the impacts, economic impact on rural
hospitals, impact on all people, not just those with Medicaid, impact on the economy, impact on jobs. we feel
that's our responsibility. So whether you're trying to make enrollment or re-enrollment harder where you're
trying, whether you're trying to, leverage work requirements, whether you're trying to cut back on certain
payments in the name of fraud, waste, and abuse, we have no problem with addressing fraud, waste, and abuse.
But we do need to be very clear about the impact of some of these changes and the potential loss of insurance of
14 to 16 million Americans.

Mark (16:05)
That's a huge, huge number. Are you working with National Governor's Association? How, how do you sort of
orchestrate, if you don't mind us getting the inside…

Dr. Betancourt (16:12)
Absolutely.

Mark (16:13)
…the beltway view of who you're working with. Who are your strategic partners?

Dr. Betancourt (16:17)
Absolutely. So, you know, we just recently, within the last couple weeks, had a visit to Washington DC. We
have a great partnership with NASHP, the National Academy of State Health Policymakers, where we brought,
with NASHP in partnership and with the Milbank foundation as well, the Milbank Fund, about 30 leaders of
health and human services from across the country. Yeah. And, brought them to dc. We meet, we strategize, we
have discussions. And when I say strategize, just sharing really in that convening. But we had a chance to spend
an hour with Dr. Oz over at the Center for Medicare and Medicaid Services. Very, very productive conversation.
clearly, I think, we were able to, the state directors, in fact, were able to provide their perspectives on what some
of these changes would mean for them operationally from an execution standpoint, from a cost standpoint. I
think Dr. Oz really listened. It was clear. He said, you know, I, I am, we are not trying to create barriers to kick
people off Medicaid. We're trying to make sure that Medicaid, that dollars go to those who are most vulnerable.
Fair. He talked about work requirements and things like, it's not just work. It could be community volunteer.
That's right. So, you know, we had a really great dialogue, and I think dialogue is what we want. and these types
of engagements allow us to find common ground. He had a lot of learnings from that group who said, you know,
how are we gonna, these, these data sets eligibility for SNAP is different than for Medicaid, right. Doing this
enrollment. I mean, this is a big thing. It's not just flip a switch on work requirements with like, great
conversation. That's the way…

Mark (17:45)
And they're gonna have to implement it.

Dr. Betancourt (17:46)
No doubt.

Mark (17:47)
CMS is gonna…

Dr. Betancourt (17:48_
Could be millions of dollars, incredible additional red tape. So, you know, at a time we were trying to, you
know, kinda limit bureau, bureaucracy, you could add a whole lot more. Right. Good, good exchange. And that's
what we aim to foster.

Mark (18:01)
Margaret, we just had a great conversation with Stephanie Carlson, the deputy administrator, who really talked
about exactly what, Dr. Betancourt was saying about this. We wanna work together particularly on the worker
requirements.

Margaret (18:14)
And you've been a champion of primary care for your whole career. I know you're trained as an internist. Right.
But Champion, still practice, Good champion of primary care. and you've, beta clear. You think there's reforms
that we need in payment and there's investments that we need to make. You also referenced the Millbank Fund,
who I've worked with on their, work on primary care shortage. I'm sure you've seen the report. Nobody will see
you now. That's right. Right. The play on the old, the doctor will see you. Now. What are your top strategies for
addressing the primary care crisis that's evolving even in the presence of people having insurance noted not
having access to a primary care service?

Dr. Betancourt (18:49)
Yeah. so I'm a practicing primary care doctor, still. I see patients for a half day, weekly practice for almost 25
years. I'd say a couple of things. We are in the midst of a very significant primary care crisis. Right. If we just
disentangle a couple pieces from a workforce standpoint, we know that we lost 10% of the primary care
workforce from 2005 to 2015, even before the pandemic 21 to 22, we lost another 16,000 primary care doctors.
Average age of our primary care doctors is now 60 years old. We have, really very, very significant
administrative burden on our primary care doctors. And I would argue demoralization the simple notion that I
want to do the most and best for my patient, and I can't, because people are getting in the way. And this is
incredibly moralizing. You line that up with the fact that there are no reinforcements coming behind us. medical
students are not choosing primary care for all these reasons.

Margaret (19:39)
Right. We see that. We see the graph.

Dr. Betancourt (19:40)
Yeah. Not to mention…

Margaret (19:41)
Dermatology down to primary care.

Dr. Betancourt (19:42)
Yup, not to mention, loan and debt. And so we have a challenge here. Now, we at the Commonwealth Fund
have had a program on primary care that's really talked about, pushing value-based payment, supporting the
community health centers, doing those types of things. We're gonna redouble that effort now, with the launching
of our new strategic plan in September, we're gonna focus on primary care and rural health where primary care
issues are even, more challenging. Right. But I think we've reached a tipping point. You know, Americans
across the country, are having incredible difficulty accessing primary care. Yeah. And providers are as frustrated
as patients. So we have a unique opportunity, I think, to, to leverage that frustration to some action. Now, sadly,
when I go to the Hill, what we hear from many, leaders on the hill is we don't hear from primary care doctors.
Enough specialists show up here and talk to us a lot about payment and all those things.

Margaret (20:32)
Oh, interesting. Primary Care Providers are too busy seeing patients.

Dr. Betancourt (20:35)
Yeah. They, they don't. Right. So we're not hearing from 'em. Squeaky wheel does get the grease. So, you know,
I think we also, in addition to value-based payment, we're thinking about ways in which, we can amplify what a,
what the workforce might be. earlier session today, talking about community health workers, navigators,
healthcare coaches, of course, nurse practitioners, advanced practice practitioners. We have international models
that demonstrate when you put all those people in a team, particularly in a value-based setting, you know, you
get great results. And so how do we drive towards that? But I would argue as a practicing clinician, it's not just

about payment. I think my peers, you know, paying them a little more is not gonna get the job satisfaction they
need system change. Yeah. They wanna be able to find meaning in the care they provide, and be able to provide
care to their patients, at a level that's, that's high quality. And so we're trying to level that all in and also really
think about technology. we're very bullish on the impact of technology and, and how it could help us.

Mark (21:25)
Well, you've made so many great points there. I just wanna pick up on a couple of, of them. One nurse
practitioners and physician assistants. Margaret set up the first nurse practitioner residency program 16 years
ago. So we're invested in that. Commonwealth Was a big supporter. Very good. There are now 500 of them
across the country and growing. and that's an important one. But, you know, it's the loan issues that are looming
large. And one of the provisions in the new bill is the cap medical school education at $125,000, which may be
one or two years, but not, not four years. And we understand that they're trying to get costs more affordable.
Yep. Because we wanna track a diverse group of population into this field. Yeah. What are your thoughts in
terms of the financing that's gonna be needed? I'd say that, and also the scholarship. you know, the money to
keep people in the, in the, field in terms of special populations, making sure there's working for those who are
interested, have the financial support for, working in underserved communities.

Dr. Betancourt (22:28)
Yeah, loan and debt are very, very significant. We do know that, it is critical to train people in community
settings and, and provide them the incentives. 'cause at the end of the day, if you have big loans and debt, that's
gonna force your hand. Yeah. I mean, where you practice, it's survival where you practice. Yep. The practice,
you choose who you choose to care for. And many people say, I'd love to do X, but I just can't. And we, we
don't want it. Number one, we need people taking care of individuals in rural settings of normal populations.
And, and number two, it's a shame if we have people who wanna do it and can't do it because of these
extenuating factors. This is gonna require a significant transformation. And, and I think tied to this is how
medical education will need to dramatically change as well with technology. I mean, we have to acknowledge
that in the next three to five years, seven years in my view, care will be drastically different. I think we will see
a re-imagining of what primary care looks like, where we have chunks of, I believe, things that primary care
doctors do now, taking off their plates done, managed in a team-based way very, very effectively at a very high,
and I think level of excellence. But the medical training, we need to adapt to that. And like all things, healthcare,
we have a lot of deeply entrenched systems I think, that are resistant to these changes. And, you know, these
changes are gonna happen whether the systems acquiesce or not, but I think the training and the debt and, and
how this plays out is gonna be really critical going forward.

Mark (23:52)
You know, Philanthropy so important. And I asked you earlier about what you're doing with, Governors’
Association or other groups wondering about other foundations across the country, how you're working with 'em
and some of these small ones, and how are you working to cultivate philanthropy? Yep. We need this next
generation and primary care is where we hope they invest, but we also hope they get engaged somewhere where
they're interested. What are you doing to sort of, tie together with, with the philanthropy community and also
trying to think about cultivating a different culture, for giving?

Dr. Betancourt (24:28)
Yeah. So I've been in this role again a little bit less than three years. I'm a big believer in collaboration. We have
big problems. I can't solve it with $25 million in grant making. Right? Yeah. And I don't have, pride of
ownership either. I think at the end of the day, we have had examples of very strong collaboratives. We were
part of something called the seven F, which is high need, high cost, older Americans that, I, began just as that
that was phasing out. We now have a collaborative over 10 foundations who are working on primary care. we
need this. And, and quite frankly, I think these crises create opportunity for greater collaboration. Yeah. We, as
foundations have also, come together, in the defense of our resources as we've, had in the bills of potential
increase in tax, our tax of, right. Right. Yeah. And so, you know, I think that's created greater connectivity
between the foundations. and I think it's connected to some foundations that are right, left and center. you know,
when I say right, left and center, I mean leaning, of course, many of them are non-partisan, but of course…

Mark (25:28)
University of Texas and Harvard are gonna be treated the same way. And they may have different political
stripes.

Dr. Betancourt (25:32)
Yeah. Ultimately, there's opportunities for leveraging philanthropy. We're never, look, we're never gonna fill
some of the gaps like the NIH cuts. Right. but can we leverage our convening power to really think about what
is the right path forward? Not just stop that. Right. Don't do that. Right. Let's not do that. Right. Because I think
we have to acknowledge it wasn't perfect. Right. Clearly there's a lot of disruption and I'd say some destruction
of what's happening right now, but what we really need is a plan forward quickly. and, and that's what I think
philanthropy could help catalyze that.

Margaret (26:04)
Well, I'm not sure that we always see where we're going as we're going. And I think one of the phenomena of
the last several years that kind of came to roost, we saw it in Massachusetts, we saw it in Connecticut, we've
seen it in other states, is the role of private equity Yeah. In healthcare, both at the hospital and tertiary level, but
also at the primary care level. Yep. We think over here about some of the pressure that primary care teams are
feeling, and that private equity role seems to be exerting influence there as well. Yeah. Does the, fund have a
position on that? Absolutely. Have you done any studies or looked at the impact specifically of that? And we
could describe it, but I think everybody knows what we mean.

Dr. Betancourt (26:41)
Yeah. At, at the end of the day, I mean, we, have done work on, again, the science behind private equity with a
particular interest in when private equity engages in healthcare delivery, what is the impact on cost, quality, and
safety. and we've done work in that space, published in that space. We are launching as part of our strategic plan
under our cost pillar, an area that's focusing on what, what have been called the commercial drivers of health.
And this simple notion that many people are feeling that there's a tension between profit and patients. that has
been played out probably in its worst case with the national story of Steward Healthcare, where really you have,
wealth extraction at the expense of health creation. Yeah. And again, we want the evidence to take us to, to the
rightful conclusion, but the evidence to date, not all private equity investments the same. Not all private equity
investors are the same, but we do believe that, we want to make sure that people are acting, with the American
people's health and wellbeing in mind. And there's accountability for that. It's not about overregulating, but it is
about making sure that we don't see steward healthcare type situations again, where hospitals closed
communities are left without clinicians. That's, and an incredible amount of wealth has been extracted out of
those Right. Hospitals. And, so it, it's complex, but, but we're there and we're gonna stay there.

Mark (28:07)
One, one of the most pressing problems of, of our day, it was mentioned in the Commonwealth, announcement
of your, ascension to the presidency that you are of Latino descent. Yes. And I'm wondering if you could share
with us that's exciting news and, what does it mean for you?

Dr. Betancourt (28:22)
Yeah. You know, this is a great opportunity. I mean, I, I think for me, my lived experience informs a lot of, of
my, ideas around how our foundation can go forward. And it's lived experience that really is about respect. It's
about making sure, again, that we leave no one behind. it is about making sure that, that I, and we do the best for
everyone. Those are the values that I bring personally. Those are the values that I bring as a clinician. And,
those are the values that are very well aligned with the Commonwealth Funds. So it's an honor and privilege to
bring my set of kind of cultural, professional, personal values and experiences to a place that has that alignment
and try to think about just making us more impactful. It is, you know, working at the fund and getting a chance
to lead the fund. It's what I call a beautiful puzzle. The pieces are all there. How do we put the puzzle better, put
it together in a way that's even better than it was before. Yep. so it, it, I think all those things inform how we
think about it. And we have a fantastic team who's aligned as well.

Margaret (29:17)
You know, I, I have to ask you - I followed your work, I think we probably both did 'cause we were doing the
same thing in Connecticut during COVID-19 - and you took on a very strong leadership role in community
health, and in the Mass general system. What are the enduring lessons that you learned from that? 'cause it
wasn't about what went on in our exam rooms, it was all about external.

Dr. Betancourt (29:35)
No, it was incredible. I mean, I'd say a couple things just related to the, to that, when we think about care and the
pandemic really shone a light on this, we need to think about doorstep to bedside and back. Our inability to
prevent the spread of, COVID, in essential workers. People taking public transportation, people in multi-gene
housing, generational housing, not kind of doing work in that space led to the incredible imbalance at the

bedside. And so bringing that holistic view is really important. And I think that's one of the key lessons. I think
another, really, important key lesson that we learned during the pandemic is, man, when stuff's on fire, how
quickly people will move. The amount of red tape that we set aside…

Margaret (30:24)
I think we completely agree with you. Innovation.

Dr. Betancourt (30:26)
And, and this innovation, and this universal focus on every minute is a life. We used to laugh during the
pandemic, and we'd say, you remember the days where you and I would say, okay, yeah, let's set up a phone call
in a week. No, let's set up a phone call in one hour…

Margaret (30:40)
On Sunday at 5:00 AM.

Mark (30:40)
With a hundred people.

Dr. Betancourt (30:41)
…with hundred people, because every minute matters. And I, and I think I, I, I do want to tie that to the
demoralization piece because the pandemic for many caregivers was the worst of times for all the reasons we
know. But it was the best of times. Because all the stuff was out of the way. And then when you come back out
of that adrenaline infused exhaustion, but exhilaration that, you know, along the way you save some lives and
now you have to deal with prior approvals, it's really tough. Yeah. And so can we get that secret soft again? Can
we deploy that type of energy around behavioral health? Another pandemic. Maternal health. Another
pandemic. So that, those are the big lessons for me.

Mark (31:18)
Well, Dr. Bettencourt, thank you for sharing a light on the work that Commonwealth Fund is doing and, for the
leadership that you're providing. Thank you. And to our audience, thank you for joining us. And you can find us
on YouTube or X or subscribe wherever you can. And again, thank you so much.

Dr. Betancourt (31:33)
Thank you so much.

Margaret (31:33)
Dr. Betancourt, thank you for all of your work.

Dr. Betancourt (31:36)
Thank you. Really appreciate the conversation. Thank you.

Mark (31:37)
Oh, that's great.

Margaret (31:42)
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