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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

Complaint to FTC: Amazon search results full of potentially deceiving ads

Photo: Nigel Kirby/Loop Images/Universal Images Group via Getty Images

Amazon does not sufficiently distinguish between its search results and paid ads, potentially "deceiving millions of consumers," according to a complaint filed to the Federal Trade Commission.

Why it matters: Joan Moriarty, research director for the Strategic Organizing Center, a coalition of labor unions that filed the complaint, told the Washington Post the group is "very hopeful" that the FTC will investigate the complaint because Lina Khan (D), a known Amazon critic, is now chair.

4 hours ago - Health

Pfizer-BioNTech: Booster doses more effective at blocking Omicron

Prepared doses of the BioNtech-Pfizer Covid-19 coronavirus vaccine in Germany on Dec. 7. Photo: Thomas Kienzle/AFP via Getty Images

Pfizer and BioNTech said Wednesday that two doses of their COVID-19 vaccine were significantly less effective at neutralizing the Omicron variant in early lab tests, but a three-dose regimen was more effective.

Why it matters: Omicron, which has been labeled a variant of concern by the World Health Organization after being identified by scientists in South Africa last month, has forced vaccine makers to reassess the effectiveness of their vaccines against this specific new form of coronavirus.

Mike Allen, author of AM
4 hours ago - Politics & Policy

Biden unveils "Building a Better America" branding

President Biden speaks on infrastructure while visiting a bridge in Woodstock, N.H., last month. Photo: John Tully/Getty Images

President Biden today launched a new website and unveiled bold new branding as part of a nationwide tour to sell the benefits of his infrastructure package.

Why it matters: The White House says passage of the new law shows the ability to "forge bipartisan consensus and prove our democracy can deliver big wins" even in these toxic times.