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Greg Ruben/Axios

Toby Cosgrove, the president and chief executive officer of the Cleveland Clinic, has had a front-row seat to how Obamacare has affected hospitals and the rest of the health care industry.

And as the vice chairman of the Commission on Care — which studied ways to improve the Veterans Administration — he became convinced that veterans have to go outside the system to get better health care, because the system can't handle all of their needs.

He spoke with Axios about these topics and why withdrew from consideration to run the VA under the Trump administration. His answers are condensed, and paraphrased in some cases, for quick reading.

On why he supports more private treatment options outside the VA:

Not enough VA hospitals to go around. Only three in Ohio — in Cincinnati, Columbus and Cleveland. "All of those are a long ways from Toledo … You just can't really cover the state of Ohio with three hospitals."

VA electronic medical records were developed 20 years ago. They're way behind the times now and don't communicate well with other systems. "They need to have an electronic medical record that is 21st century."

And if there's another war, how will the VA system ramp up and ramp down?

"They ought to have access to the private health care delivery system."

On his discussions with the Trump team:

"My initial discussion with them was, were they willing to make that kind of a major change, and if they were going to make that major change, was it feasible to make it happen?"

The focus — at least at the time — was on eliminating the rule that only allows veterans to seek care outside of the VA if they would have to wait more than 30 days for an appointment or live more than 40 miles from a VA facility.

On why he withdrew:

It was a tough call, but the clinic had already started several billion dollars worth of construction and new projects. "I had to weigh that against my commitments to the Cleveland Clinic and the things that I'd started here that I needed to see through."

On the Affordable Care Act's hits and misses:

"We needed to do something that moved us from paying for volume to paying for value. I think that was something that was really pushed hard by the ACA."

Quality metrics have improved "gradually," including reduced hospital readmissions. And, of course, 22 million people gained coverage.

Health care inflation came down, but is now rising again. So the law's effectiveness in controlling costs is "probably open for discussion."

But the law "really did not do very much" to push people to stay healthy — partly because it's politically unpopular to tax cigarettes, and the powerful sugar lobby will always fight efforts to reduce obesity.

"I think that was one of the misses, but I understand why it happened. But I think that's one of those things you could correct going forward."

On the need for hospital consolidation:

"What you need to think about is how you bring hospitals together to work as systems."

In Cleveland, the clinic entered a partnership with MetroHealth System to coordinate trauma care — it closed all but two of its trauma units and steered the most badly injured patients to MetroHealth. Result: the mortality rate for trauma was cut in half "by simply having a concentration of quality places doing lots of volume."

"On one side of Washington, you have the Affordable Care Act saying you've got to be more efficient. On the other side of Washington, you've got the Federal Trade Commission and the Justice Department saying, well, you know, you can't bring too many hospitals into the same system."

"Health care has remained a cottage industry ... It really needs to consolidate, and it really needs to bring efficiencies."

On the clinic's shelved initiative to create its own health insurance plan:

They looked at the idea and there were "pluses and minuses," but for now they're going to keep working with the major payers and try to have as many as possible.

Go deeper

"No-code" miracle for startups

Expand chart
Data: Interactive Advertising Bureau; Table: Axios Visuals

The U.S. has reached a tipping point in its shift from the industrial economy — one that relied on the buildout of hardware — to an information economy that relies on the transfer, storage and implementation of data, according to a new report.

Why it matters: This shift towards a data and information-based economy has allowed more businesses to establish themselves and scale quickly and at a very low cost. As such, the number of jobs created by the commercial internet has more than tripled since 2012.

Amazon's small business shield

Illustration: Aïda Amer/Axios

Amazon is touting the success of small sellers on its platform through the pandemic — and warning that antitrust legislation could jeopardize that success and blow up its open-marketplace model.

Why it matters: As online shopping became a lifeline for both businesses and consumers during the pandemic, Amazon reaped big benefits, but also saw its regulatory risk grow.

The new cold war panic

Illustration: Aïda Amer/Axios

The world has seen a power struggle between nuclear powers before, and has seen those countries inch closer to military conflict. But it's never before seen a cold war between two countries as interconnected — with each other and with the rest of the globe — as the U.S. and China.

Why it matters: Escalating antagonism between the world's two superpowers is likely to hinder global cooperation to fight climate change, divert resources to costly arms and tech races, complicate diplomacy for U.S. allies, and victimize Chinese and American citizens living in each other's countries.