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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

Bernie Sanders: U.S. must recognize that "Palestinian rights matter"

Sen. Bernie Sanders. Photo: Stefani Reynolds via Getty Images

The United States must encourage an immediate cease-fire in the Middle East and adopt an "evenhanded approach" that recognizes Palestinians and Israelis have a right to "live in peace and security," Sen. Bernie Sanders (D-Vt.) wrote in a New York Times opinion on Friday.

Driving the news: Violence escalated this week after Israelis intensified efforts to evict Palestinians from their homes in Jerusalem. Hamas fired rockets and Israel massed troops, leaving more than 125 Palestinians and seven people in Israel dead.

3 hours ago - Technology

Exclusive: Uber makes new hire, launches anti-racism campaigns

Illustration: Aïda Amer/Axios

Eager to show progress on the pledge to make its platform and business anti-racist, Uber on Friday announced new anti-racism driver and rider campaigns, as well as fresh internal hiring practices, Axios was first to report.

Why it matters: Uber is one of the biggest ride hailing companies in the world. Its decisions impact the millions that use the platform, where drivers and riders alike say they have experienced racism.

Ex-Gaetz associate admits to sex trafficking, will cooperate with federal prosecutors

Rep. Matt Gaetz (R-Fl) speaks during the "Save America Summit" at the Trump National Doral golf resort on April 09, 2021 in Doral, Florida. Photo: Joe Raedle/Staff via Getty Images

Joel Greenberg, a former associate of Rep. Matt Gaetz (R-Fla.), has agreed to cooperate with federal investigators and admitted to a variety of federal charges including sex trafficking a minor, the New York Times reported Friday citing court papers.

Why it matters: Investigators believe Greenberg introduced women to Gaetz for paid sex and are looking into the Florida congressman's alleged sexual relationship with a 17-year-old girl. Greenberg could be a key witness as federal prosecutors decide whether to charge Gaetz.