Kevin Kincaid (00:00.3) Okay. I'm Kevin Kincaid. I'm the CEO of Knoxville Hospital and Clinics and this is the Prairie Farms Podcast. Perfect. Perfect. Nicolas Lirio (00:10.798) man, I I think people I am very biased towards Knoxville, but I think people think that I just like pick whoever I want from Knoxville. But you have way more credentials than just CEO of Knoxville's hospital. I believe our community's super privileged to have you here, but you've done a bunch of other stuff, including work on a nuclear submarine. Yeah. Kevin Kincaid (00:36.622) Yeah. Kent Boucher (00:37.281) Really? Nicolas Lirio (00:39.106) Yeah. You don't listen to my podcast, Kent. Man, you're a fake friend. Kent Boucher (00:42.791) You haven't ran your podcast in over a year. Just under a year. Okay. Yeah. And that's not true. I have listened to a lot of your podcasts. But so what were you doing on a nuclear submarine? Nicolas Lirio (00:45.078) No, it's been just under a year. Kevin Kincaid (00:52.386) Well I I went in and I was a sonar tech and after so I was on I was on a ballistic missile submarine out of Holy Lock, Scotland. Wow which is basically you drive around in monster areas it I've been there. I w I went there when we were in Dry Dock, so that was cool. Iverness, I believe, is the town that's closest to there, but Kent Boucher (00:58.954) Serving in the the Navy. Kent Boucher (01:10.958) Yeah. Kevin Kincaid (01:22.434) So I had a ballistic missile submarine, so we carried you know the when we went out to sea, I believe the number was we were considered the fifth most powerful nation in the world, that submarine by itself once it submerged, just with our firepower that we carried on board. So a lot of destructive power. And basically at that time you drove around in a predetermined area of the for us it was the North Atlantic and we had pre-targeted missiles for the most part. And we drove around at launch depth and floated a wire, stayed in constant communication, and were ready to launch missiles. I did that for a few patrols and then then I ended up in Pearl Harbor, Hawaii, clear over on the Pacific side on a fast attack submarine which was a completely different world. And we went out and kind of found trouble on that. We did a lot of intelligence gathering and did all sorts of things. you know, this was in the you know, the late eighties, so we're talking the Cold War, so cat and mouse with the Soviet Union for the most well, almost exclusively. And so yeah, it was super interesting life and then when I decided, you know, hey, this I love that job to be honest, you know, the ears of the sub, you know, w and essentially the eyes as well. And being able to listen to things in the ocean and get good at what you're hearing and then use the computer technology we had a time to refine it. But no, I could tell the difference between, you know, hey, that's a submerged submarine making steam noise. That's a nuclear sub and it's not one of ours. versus that's a fishing trawler or, you know, that's biologics, a bunch of whales or shrimp making noise. I love that job, but Nicolas Lirio (03:25.032) Was that scary if it was another nuclear submarine that wasn't yours? Kevin Kincaid (03:29.718) it was interesting for sure because you had to figure out who it was and a at the at the time we were so far superior in our ability to remain undetected and quiet. And I like to feel we still are, but I'm not in the know right now that we we followed Soviet submarines all over the Pacific Ocean within sometimes we'd get within just a few feet. I mean a few feet of them and they not know we're there. Wow. And so that is kind of some interesting stuff, but I felt like we were the best. I d we were the best and and we were good 'cause we were the best. We had the best equipment and the best training. Well Nicolas Lirio (04:19.486) One million dollars three weeks on the submarine, Kent. You do Kevin Kincaid (04:22.37) Yeah. Kent Boucher (04:23.122) Just for the never just for I mean yeah, I'd be claustrophobic and everything probably, but just the that that is something that has always fascinated me. Not like to the point where it's like, you know, I'm a a little kid just like researching everything I can about but I just always been that at school. In fact I think man, I've met so many thousands of people in my life. I think you're the first person I've ever met to have been on an operating submarine. Yeah, that's that's r that's really nervous. Kevin Kincaid (04:50.146) Yeah, it was a super interesting story, you know, the you know, it's where you can travel around the world and see none of it. Yeah. Nicolas Lirio (04:59.96) Yeah. Kent Boucher (05:01.878) I w that's what I wanna know. Kevin Kincaid (05:04.142) I mean just some some oddball things like so when you say see other than the small glass on a periscope there is nothing there's no nothing you can see. So they're not yeah, yeah. It's not like the you know, Atlantis or something. Yeah. but one of the th one of the things that is things that you hear that you don't know what that is or in the Indian Ocean one time Nicolas Lirio (05:16.347) there's no yeah. Kevin Kincaid (05:34.11) there was this feeling like we hit something, like we we hit if could feel it, you know, 'cause if you're submerged, I'm gonna say below say s four hundred feet, maybe six hundred feet, you the sub feels like in this room. There's no movement, there's no nothing. You know, even if you're moving. Yeah, yeah, you're moving, but it feels very solid 'cause the C's not really moving you around. Now if you start coming up, especially in the North Atlantic, you start cupping up to a couple hundred feet, the the the rough seas there, you're gonna feel that and you're gonna start tipping and turning and then you'll be reminded you're on a boat. But when you so in that very stable environment you can feel very small things and it it felt like we hit something and you know, we just never would know. But you know, there was we almost lost a sub just outside of Guam a few years ago that that hit an undersea mountain at flying speed and it tore like the whole front of the sub off. They almost lost the sub. There was at least one sailor died, a lot of people got hurt, just hit an underwater mountain. And 'cause you can't you know, like and that's the thing about But mountains are changing, you know, these are s and you know, and and we like to think we know a lot about the ocean floor, but there's a lot of things that aren't mapped to the detail that you need. Kent Boucher (07:06.008) Isn't it the the the moon has been explored more thoroughly than the deepest parts of our earth? Kevin Kincaid (07:12.286) Yeah. And and we're not going there, but certainly one of the things is that our our secret sauce in the submarine service, which we're referred to as the silent service. And 'cause that's your that is your competitive advantage that you are so quiet, no one knows you're there and you can do what you want. so you can Kent Boucher (07:17.868) It was pretty close to Kevin Kincaid (07:39.894) Rest assured we got folks around the world that are doing what needs to be done and no one knows they're there. Yeah. and that's you know, that's a pretty cool feeling that we're that good at that. But what that means is like when you hear like think about the the sound of submarines, you know, like on the movies you'll hear p you know, that's active sonar which would tell you, you know, hey, there's something up there because you'd have that reflective sound waves. Kent Boucher (08:00.6) Ding. Kevin Kincaid (08:10.178) well we rarely do that because if you light off active sonar, everybody in the world knows well, you know, that's we know now where you're angry and we probably through intelligence know what your the the hurts or the tonals are of that particular submarine's active sonar and then they got you pegged. So we just didn't do that very often. I mean it's extremely rare. So you're going off charts. Yeah, that's they're not perfect. Kent Boucher (08:37.678) It's s just such a weird it's kinda like the first time I remember when I was in high school I worked for the s the school district I was attending and they would let us operate equipment that we had no business operating as sixteen year olds. And one of the first things that kind of threw my mind it was very simple, but they I had to drive this big box truck t with you know, loaded up with school supplies or whatever from one school to the next. I remember I went to look up at the rear view mirror you know, to like back up. I'm like, wait a minute. There's no turning around and looking behind me. I have to rely solely on these mirrors here to not run somebody or something over when I go to back up. And you know, it's kind of like a wow, I'm very dependent on the this this equipment that's here to trust it. Or if you ever use like adaptive cruise control on a vehicle the first time you're like I'm just totally reliant on this equipment. Kevin Kincaid (09:29.35) yeah. Kent Boucher (09:33.688) But for a submarine, it's you literally can't look out the window and double check. You can't get out and open your door and see where are you. You it's completely on the the equ. Kevin Kincaid (09:43.238) And just the physics itself, you know, that that people that so they have what we call the main ballast tanks or ballast tanks throughout the sub, which helps us stay level when we move water from one one tank to another. But we have these huge tanks and that's how it submerges. Hm. I mean, you flood in thousands and thousands of gallons of seawater and fill up these tanks and that's how you g you submerge. And then you've got kind of like aircraft, you've got fair water planes and stern planes that control your depth along with your propulsion. and so like the USS Thrasher that that one of the nuclear subs, one of only two nuclear subs that we've lost, You know, that created what was called the sub safe program, like you know, a lot more safety and the ability to get that water out of those ballast tanks should you need to go to the surface in a hurry. You know, you have because the two things on a sub that that are, you know, like horrific is flood and fire. Those are the two things that you there's no place for those toxic fumes to go, you have a major fire on a sub and it just it becomes uncontrollable. It's a highly oxygenated environment. Fires are a bad deal. Flooding, obviously. But when you're on at depth under pressure, a small hole in, you know, say some sort of seawater pipe can create massive flooding and a lot of, you know, really get your attention in a hurry. But you know, it's a it's a unique thing, you know, 'cause the only limiting factor of how long a submarine, a modern submarine, can stay out at sea is food. Because you have unlimited propulsion, you have nuclear power, it's unlimited. You've got you make your own water, you make your own oxygen. You could stay out forever, but you run out of calories, yeah. And so yeah, that's how Nicolas Lirio (11:50.424) you not hate the people you're in a tiny box with Kevin Kincaid (11:53.646) you hate a few. Kent Boucher (11:54.888) But but the desire to survive is y what's Nicolas Lirio (11:56.674) Yeah. Kevin Kincaid (12:01.646) Yeah, and there there is a brotherhood that is hard to imagine. Say if you go out to sea with a hundred and eighty people on this in incredibly cramped quarters and you're hot racking, which means three people to two beds. You have to rotate who's sleeping when. you know, the the only social part of the places, you know, chow hall and and food's always good on sub, which is kind of interesting. weight management became a problem on submarines because if you're exercising, you have a chance of making noise. Like you can't have a w like barbells. You drop on the floor and that could be a death sentence if you're in the wrong you know, like you can't do that. So, you know, it was hard to exercise. It was hard Food was good. So yeah, but yeah, my my point with that is is that you know these people like you know everything about them, you know, by the time and and you just become extremely tight and and you like like anything, you throw a hundred and eighty people together, you're not gonna like all. Yeah. And they're not all Yeah, that'd be a rough number. Nicolas Lirio (13:19.758) How big is the sub? Kevin Kincaid (13:24.584) well, depending on what kind it was, the ballistic missile submarine, which has a giant three story missile compartment, may is, you know, maybe between four and five hundred feet long. Realize these things are big. These things are very, very big, and then the fast attack was like two hundred and eighty some feet long and but they're not designed for that many people, so that's why when as these ships are built. Nicolas Lirio (13:37.23) I don't know. Kevin Kincaid (13:53.388) And then they come up with, hey, let's put this new piece of equipment in. Well, living quarters is what gets sacrificed for that, you know, sort of thing. So really the the boats would go at sea, depending on what your miss you know, the ballistic missile submarine had one mission, one mission only, and that's to be launch ready at all times and remain undetected. That was your only job. And then on fast attacks, of course, you've you're you're picking up depending on what you're being sent out to do for intelligence gathering, you might stop and pick up specialized linguist or people that have in the intelligence community where we can pop up to Periscope and look at something and then they can tell us what we're looking for, you know, take pictures and all that kind of stuff or make recordings and yeah, so fast attack life was amazing. You know, I didn't appreciate it, but the guys that were married It was kind of interesting because the ballistic missile submarine, you were out and you were in. And everybody, your family knew when you left and they had a real good idea when you were coming home. The fast attack world it would be like, Hey, we're gonna leave on Monday morning and we're gonna go test some equipment and we'll be back next Monday. We're gonna go do some sea trials and we're gonna, you know, do some pr drills and things. then we pick up a Soviet boat or we get orders to go do something. There's no mail service or telephone communications and and we may be gone for a month or two. So could you imagine you know, like your family dad didn't come home and I don't know when he's coming home, you know? It's a so that's coming that that family sacrifice around sub service. I mean there's a obvious any military thing has this huge burden on families. It's huge. But though the uniqueness of submarines was the lack of the ability to have any kind of communication. I mean we would have the things called family grams and things, but they were very difficult to use. We would maybe communicate through some radio transmissions and things with family and but you know they would never give you you Kevin Kincaid (16:16.91) You know, y you you had one of your parents passed away or something, they're not gonna tell you that while you're out of sea. You know, you're not you're gonna get that news when you get back in, so That is Nicolas Lirio (16:27.662) That is a crazy that is not wasn't on my bingo card from Kevin Kincaid (16:30.796) yeah, it's Yeah, I f I forget about it sometimes, you know. It's one of those things I wouldn't want to do it again, but I'm glad I did it. I was young and had no zero direction in life, had no I just kinda stumbled into the it's nothing I had thought about. I put zero thought into it. I was literally been kicked out of college. I'm walking around the streets of the Kent Boucher (16:31.746) Yeah. Kevin Kincaid (16:56.386) community that I was in, I can't go to school, I don't have a really a good job, walk by a recruiting office and it was like, Well, why don't I do that? And then got in there, well yeah, you should do this. And then well how about submarines? Well sounds good to me. You know, so there was zero planning and and but I just kept you know like that's one of the things like working in a hospital, I'm surrounded by brilliant people. Mm-hmm. Just that's the I mean, you just there's not room for duds in a hospital. Yeah. Submarines, wow. I mean, I found myself all the time like, Why am I here? Everybody's MIT grads, Stanford grads, you know, Naval Academy grads, and I'm surrounded by the smartest engineering folks, weapons folks, and I'm like, wow. How am I with this group of people? And I feel the same way in a hospital. Like, you know, when I interact with, you know, our providers and our you know, just the people that work here, the technical staff, whether that's IT or lab techs, x ray techs, I'm like, I can't compete with these people. They are just brilliant. Mm-hmm. Kent Boucher (18:11.48) Th I g I gotta know, do you have any real close calls when you're on the submarine? Like whew, if we didn't if we didn't, you know, roll this way instead of the other way, that could Kevin Kincaid (18:23.062) Yeah, there's lots of those. When you're Kent Boucher (18:27.084) Is it more a at risk of being attacked or is it more of a risk of like some underwater hazard or something breaking on the on the vessel? Kevin Kincaid (18:33.172) doing what we were doing by far the most dangerous thing was underwater collisions. Yeah. You know, and they don't know you're behind them or what you know, like and and so that was probably by far and then just the dangers of the environment, you know, deep Deep ocean stuff is not tiddly winks. You know, it's a it's a very tough environment on it's tough on everything, equipment and you know, you got all that high pressure. and you've got serious weapons on board. Yeah. Kent Boucher (19:21.686) Yeah, which all have to be able to withstand that pressure too, which is so amazing. Kevin Kincaid (19:24.811) Yeah, yeah, and and yeah, you just you know, and you're carrying nuclear weapons and just it's very serious business. Did you Kevin Kincaid (19:37.714) No, I you know, th there we we drilled for that a lot and you know, just if we came close, you know, y you would know about it as much as I would, you know. It it just you know, I think we had some world events, you know, things happen that none of us know about because there are people in the know and this is just not something they talk about. But, you know, over time things begin to kind of leak out or You know, I th I think the closest by f by far was, you know, the Cuban Missile Crisis. where, you know, it sounds to me like the the officers in Cuba had permission to launch and chose not to. Hm. the s the Soviet you know, some of the Soviet nuclear subs they they they did not have the concentration and safety we had. And so there was Kent Boucher (20:23.395) Yeah. Kevin Kincaid (20:36.466) they made a couple of movies about it, but you know, lost control of their reactors, you know, and potentially could have ruined our entire eastern seaboard. you know, with nuclear contamination and things like you know, there's a lot of risk that happens and just you know by divine intervention it just didn't go that way. And so one of the Kent Boucher (20:46.723) Yeah. Kent Boucher (20:59.554) most amazing stories I've ever heard was I want to say it was called the Squalas that was up by New Hampshire. It was a submarine that I think they had an intake pipe that ruptured or something and started flooding the sub. And they weren't super deep. They were just drilling right off right off the coast of New Hampshire, I believe. And they had the there were some some there was some loss of life. I think there was there ended up being a small explosion or something inside. And they were you know, they had to shut off that end of the sub and then they were basically just, you know, run down to hours of oxygen left and they used one of those diving bells to rest it was like a brand new technol I think this was back in the fifties or sixties. Brand new technology and they would like carry it was able to carry like two people Kevin Kincaid (21:44.802) Yeah. Kent Boucher (21:56.074) off the sub at a time and it it lower what'd they have? Like a is like a cable or something that they they tethered to the sub, like right at the hatch. And then it would it would be this big watertight enclosure that would go from the ship down to the sub and then it would open up and maintain a watertight seal with with the top of the sub and then like two guys plus the guy who's running the diving bell down could could fit in there at a time and like you're saying it's you know over a hundred people. Kevin Kincaid (22:25.23) And it's it is kind of interesting. So in sub school you learn how to run that and operate in that escape hatch. And then the first time, you know, that we went out on operations, you know, the last thing that was done before we shipyard workers came over and they welded the escape hatches shut. And I'm like, Hey what are we doing here? you know and it's like, Well, you know, guys, don't tell your moms about this but we we don't have no escape hatch, you know Kent Boucher (22:46.531) Kent Boucher (22:54.604) that's spooky. Kevin Kincaid (22:56.59) Yeah. And what's and and kinda the theory is those things had come open underway and they start clanking and banging and then you're you're n it's not that it's gonna flood, it's the outer it's the outer piece. You'd you cannot have that come open, it would make noise. And so and then Kent Boucher (23:07.874) Done. Kent Boucher (23:18.316) it'd make noise and then you'd be prone to be you'd be dead in the water or something. Kevin Kincaid (23:22.104) Basically v for just a minskal amount of time would we be operating in water that's shallow enough now in modern in modern submarine, you know, activity, to where a diving bell would be you couldn't do it, you know. But if you remember the s last Soviet boat that sank the Kursk, but anyway they they had a diving bell that Kent Boucher (23:40.142) The rest of the time it's just you're in a tune. Kevin Kincaid (23:51.746) They were able to get it but it was too late. But they had people but that survived the the explosion in the engine room but they succumbed to you know being cold and running out of oxygen. But they did get a diving bell on that and the Swedes I think actually did it and but when we went on ops, yeah they welded them shut. So there wasn't a Kent Boucher (24:17.934) That's a fascinating story. I had no idea that was gonna be on that. I think we should just change the podcast to submarine. Kevin Kincaid (24:21.378) Yeah. Kevin Kincaid (24:24.867) Well Kevin Kincaid (24:28.406) Where is the submarine strike? Nicolas Lirio (24:29.612) While while we got ya, an expert in rural health care. I am curious, let's just start right with the the big meat of the on the bone, the big beautiful bill. Yeah. So it's gonna change rural healthcare dramatically, but I don't understand how. Kevin Kincaid (24:51.852) Yeah, so that was a massive tax bill. Just massive tax bill. And so when when you there's this arg you know, like there's this initial like the hospital community, we would talk about Medicaid cuts. And you know, and supporters of the big beautiful bill, HR one would say, well Th there there aren't any Medicaid cuts, you know, and as a matter of fact, we're gonna spend more money next year than we did this year, and you know, and there's just this kind of technical argument going back and forth. And in a lot of ways you could say, Well, yeah, okay, you're both right, but just if we look at pure math, we're talking about a trillion dollars, you know, that we were expecting that we would get paid. on the vehicles, the complicated vehicles through the Medicaid payment program. So you've heard you may have remember this that there there were people referring to provisions in the in in how Medicaid is paid is you know you know that's like a whereas Medicare is purely a a federal government or a federal program. Whereas Medicaid is a partnership between states and the federal government. And so there's this really complicated, I mean, it i if I explained it to you in detail, we'd be here for six hours and then you'd all have headaches. But basically there's this thing called provider taxes and directed payments. And so essentially what that is is that hospital communities, like so hospitals, we pay a tax. We tax ourselves, and then we draw down a a d what's called directed payment from the Medicaid program. And so some states, not Iowa by the way, but some states were like, okay Kevin Kincaid (27:13.26) That program can't work without the state's involvement in that. It's you know, so the state is the partner in that. So the hospitals pay a tax and then the state pulls down a higher percentage of the Medicare payment through directed payments and then they distribute that to hospitals. So there were I think over three hundred directed payment programs across the country. Iowa only has two. There's the main one for all Iowa hospitals and then the University of Iowa has their own. And so the the way that that became sometimes people started referring to that as money laundering, which was a scary thing for me when I think about a payment mechanism that is crucial to our economic survival being referred to as money laundering. I'm like, my gosh, how are we gonna correct this narrative or talk about this in a different way. so what was happening is some states were saying, hey, because we're helping you through this through this program, we wanna assess a fee and then we're gonna state is gonna use that money how we want. So if you think of Iowa's directed payment program was like one point or is one point five billion dollars, imagine some of the other states, like how how much money we're talking about here. And so if a state says, Well, okay, we we wanna take twenty percent of that as a as a fee and then we're gonna use that for public schools or we're gonna use that for roads or Nicolas Lirio (29:01.166) So the money that's coming in from the federal level, they're swiping a percentage like Kevin Kincaid (29:04.802) gets depress shaving some off and so Yeah, that's been going on forever. And so that's that's not the intent of the program. But but it's you know, people get you know, states are struggling with their own budgets and how this all works. But as usual, Iowa did it by the book, very conservatively did that. The state takes out a fee that's directly relative to the costs they have, because they have to hire people to administer the program. The Iowa Hospital Association administers the program on behalf of Iowa hospitals. They take a small fee, but you know, I c I wouldn't want to tell you the exact percentage, but it way up into the nineties goes to where it's supposed to go to the hospital. Compared to the Yeah, massive amounts of that money is going somewhere else. So Kent Boucher (29:56.174) So but who I mean, you don't I don't think you'll get yourself in any trouble here, but what are some of the states that were taking huge amounts? Kevin Kincaid (30:04.754) your usual suspects are are at the top of that. I mean they're they're yeah, they're taking some big percentages, but also I'm pretty sure Texas had a pretty good chunk and fla I mean it was if you're trying to work on it th this this really wasn't a red or blue sort of thing. It was this how strong yeah like and and and so Kent Boucher (30:08.428) So like places like Illinois and Nicolas Lirio (30:26.754) Yeah. Kevin Kincaid (30:34.358) just kind of what are you know what are your budget constraints and and what arguments are you making about the program. And clearly, like a lot of government programs that I'm involved with is that there is this w which w I wanna kinda get to a point that I think is incredibly important about how healthcare is funded. But essentially it starts off as this as this incredibly thoughtful and important way to support the health care for the people that we take care of. And then it goes into the bureaucracy, and then you get a few fingers in the cookie jar, and then you get some over here. And then by the time it filters down to the patient that actually gets the care, and we're trying to pay for this, it's been diluted. tremendously. And I could go on and on about all kinds of government payment programs that are related to healthcare. And so I could go through directed payments, provider taxes that we've talked about a little bit, which was directly in that big beautiful bill. And I should stay on that because one of the things that we were able to I I guess maybe negotiator to talk about is that If if you pull out one point five billion dollars day one from healthcare in Iowa, and you're you're you're you're talking about a massive problem. There's not we don't have those kind of margins to just all of a sudden day one do that. Nicolas Lirio (32:15.104) Who's when you say we negotiated, who's we Kevin Kincaid (32:17.88) We so I most the most lots of people were talking about this for sure. But I think most of the credit goes to the Iowa Hospital Association that is very organized, very recognized. you know Yeah, we all did, yeah. And and and we had a a small group of us that are myself included, I am Nicolas Lirio (32:35.086) Yeah. Kevin Kincaid (32:44.832) very passionate about health policy. I'm very interested in policy. I I can separate myself from my personal political beliefs and I look I can I can work with anybody when I'm trying to figure out how to fund to take care of the people that I love here around our community. Nicolas Lirio (33:03.36) behind the scenes I I can vouch for that. I've seen you go against, you know, well this is what I believe personally, but you're the person in charge and you're the one and we need to make good decisions here. I've seen you do that. So and you were at one point were you the presid or chairman of the board? Yeah. I you you're not currently though, are you? Kevin Kincaid (33:20.942) No, I've I'm still on the Iowa Hospital Association's board, but I I've served all the positions on the executive committee, including the chair of the of the board. And so that was during this this time. Nicolas Lirio (33:36.086) You said you negotiated instead of ripping out one point five billion, what did you n like what are they doing now? Kevin Kincaid (33:42.158) So in right now the program is still in place. So when somebody says there's been no cuts, that's true. But it's coming. And so in July of twenty twenty eight it starts to scale down. And so what ends up happening is the term that they use is that it's gonna scale down by ten percent a year till it gets to the upper limits of Medicare payments, which it means essentially the taxes that we pay would be equal to the pa it goes away. It's zero. Okay. So then you would just you know, take or you would disband the program. So so that that directed payment program, you know, like when you're trying to figure out like how to f you know, like that I'm careful about casting stones at people. For the people that voted against the if if it was me personally, I'd have voted against it. But I also have to say I was not in that seat and I don't understand the pressures to get on board or to the pressures to vote against it, to vote for it. I I'm very careful about casting stones because you have to fund the federal government. I mean, there are there are things that have to be funded and if anybody's looked at current funding we're in a big deficit. And and then we were talking about the the economic issues that every family might suffer if the tax increases you know took effect. And so, you know, they took money out of this spot. And so like when you think about you know, I don't know, I think it there's an old famous saying of, you know, like John Dillinger, why do you rob banks? And it's like, well, because that's where the money is. Mm-hmm. And when when the federal government needs money, big money, to do something about the deficit or to do something about taxes or whatever, y there's there's only big the big places to go to are defense. And does anybody see any I any path of massive decreases in defense spending? I don't. Kevin Kincaid (36:05.356) I don't see that happening. Social Security. Yeah. Social Security. Yeah. Well, that's not gonna happen. And then so Medicare, Medicaid. that's typically a big target. And one of the reasons that it's a big target, because it's a very complicated program. Extremely complicated and the payment mechanisms behind it. So people don't understand and then when I explain them to people, they'll go, Well, that's dumb. Kent Boucher (36:06.659) Yeah. Kevin Kincaid (36:34.178) Why would you do it that way? And it's like, well, but that's how I get paid. And so all these programs, and I could give you a list of 10 of them, are built on top of the fundamental fact that we are underpaid for taking care of up to 60 plus percent of the people we take care of. So for instance, this would be like Casey's. Kent Boucher (37:11.671) Simply because you can't get b blood out of a turnip. Kevin Kincaid (37:14.71) Right, so they shows up there. They underpay us for the knowingly, they know this, that if you come in and you're a Medicare patient and you need a surgery here at the hospital, they know that my payment for that service is going to be less than the cost the cost that for me to do it. Who's they? They know the hospital. The the the federal government. CMS, the it's a it's a in the government mechanisms. Nicolas Lirio (37:38.306) Who's they Kevin Kincaid (37:44.8) So what happens is so like you would go, Well, Kevin, how are you not bankrupt? Because they set up special programs and they set up these special programs and no one has really developed the appetite to pay us appropriately in the first place. Okay. And the reason Kent Boucher (38:04.686) So that one point five billion is just that special program? Kevin Kincaid (38:07.362) Yeah, that's a special it's a stop gap. Yeah, yeah. So th that is what we've been living on. But the problem is when I explain that program to the general public, or or any rational person, they would go, Well, I don't like how that works. I don't like what states are doing with Medicaid dollars or I just don't I think that's a convolu and one point five billion dollars, that's too much and all these things. But But there are other programs. And then what they'll do is some of these programs are year to year. So if you change the the base payment of what you're paying for, that kind of becomes forever and it's super scary when they're trying to put budgets together. So in my experience, the federal government is way more likely to set up some special little program that's wildly complicated. And you may or may not get it down the road versus go let's go to the fundamental issue is that you are underpaying providers, doctors, hospitals on your government payers, which in a lot of places is the majority of the people that you take care of. So you just don't have the volume. Yeah, then that's you know, Medicare, Medicaid, any the other. So so there's a term Nicolas Lirio (39:27.276) People on government health care is what Kevin Kincaid (39:34.946) The and maybe you've heard it's called cost shifting. So forever since I've been involved in healthcare is that you we knowingly say like it, you know, we don't provide that, but I I've heard of people that have had to take a helicopter ambulance ride. You're talking less than a fifteen minute ride and you know they got a fifty thousand dollar bill. It did not cost fifty thousand dollars to fly that helicopter, you know, for fifteen minutes. But you got charged that fifty thousand dollars because the ten people before you didn't pay anything. So this whole cost shifting thing over to the private sector. So when most people have an employer-based healthcare plan, those folks, those plans, those Companies are being overcharged to make up for the underpayment of government programs. And that's how the system has worked. And then companies kind of got to the point where, hey, we can't do this no more. It's too ex it is. Healthcare is too expensive for the average person out there. but you got a big chunk of people that I mean that we could really get into a lot here, but Healthcare is this weird thing where you've got a big percentage of people that they could care less what it cost because what it cost is not what they pay. They have insurance. So I don't care what it costs. And so that's a bad economic model, no matter how you look at it. Nicolas Lirio (41:22.946) Yeah, the the power of incentives is overwhelming in the human condition. And when we separate what we're having to pay for from outcomes, we're that's not a good model. It it it's like a kid who never has to actually pay for anything they get, whether it's a car or pop school or whatever. Kent Boucher (41:42.86) Or they get they they get full control over the T V. Yeah. Yeah. They're not gonna they're not gonna say, you know what, it's been five hours, I should probably go and fold some laundry for them, you know. Well the same thing's happening with homeowners insurance as well, where I just got my updated policy for the next year in the mail yesterday. That's fun mail. And I just noticed that what a lot of the different limits have been Nicolas Lirio (41:46.616) Yeah. Nicolas Lirio (41:54.06) Or maybe it's some Kent Boucher (42:12.98) have been reestablished. And I think a lot of that has I mean, we have had some crazy storms for the last five years. Well even longer since twenty twenty that w wasn't that when the first Dura showed I think we've had one or two I know for sure we've had at least another one, maybe even two Duracios since then that have swept through Iowa. And so there has been like, you know, more out you know, large scale weather damage problems but this Kevin Kincaid (42:25.804) Yeah. Kent Boucher (42:43.126) This I I think people probably have always done this to some degree. you know, I got a little hail on my roof. You know, better call call the insurance and maybe I can get a new roof out of this, you know. But n there and I don't see around as much anymore, but for a time in there, there are these storm chaser contractors who'd go and hit every house on the block and be like, you know, better get those gutters checked, better get that siding checked. And I noticed that the the out of pocket deductible for hail damage to your siding is for my policy went from one thousand to five thousand dollars. And it's the same situation. Everyone was treating that as a cash out timed anytime a storm rolled through to get the whole outside of their house up to Kevin Kincaid (43:30.838) Yeah, to get to get people to make that shift though is like if you think about like what what are some solutions that could make some fundamental change in how people interact with their own healthcare economically. So if you think about your auto insurance, mm when you go to get your oil changed or a new set of tires, you don't turn that into your insurance. That insurance is for catastrophic sorts of things, even Nicolas Lirio (43:56.686) Sa yeah. The difference between health care and health insurance, I think we don't th it's Kevin Kincaid (44:01.482) Yeah, no, no, it's a it's a very important topic because you know, you would ask you would have to ask people to make a fundamental change and and you have to remember a lot of people like what they got. Like they they understand like like good people in Knoxville, great people, don't like the idea that the underprivileged in our community may not have access to the same health care that they do. But now ask are are you willing to drop your coverage parameters to make it available for other people? Then that now that conversation changes a little. Like I want everybody to have what I have, but I don't want to come come down. So this idea of somebody like myself that all I am entirely focused on Kent Boucher (44:52.344) That funding's gotta come from somewhere else. Kevin Kincaid (45:00.834) you know, like I have my Knoxville hat that I wear, but like when I'm doing statewide work, I think the especially rural Iowans should have the same access to quality care regardless of your zip code. And that's not true. And I wanna I I want to fix that. But to fix that requires economic investment and I just got done saying the thing is too expensive to begin with. Mm-hmm. And so it becomes it it it becomes very difficult to make the necessary changes when most people are like, look, I kinda like what I got, so don't mess with what I got. but go ahead and make the changes and then we recommend changes and it's like, well, there's no money for that, you know. And and so we're kind of just stuck in this vicious cycle of trying to come up with new payment models. on top of a flawed pro you know, the the old analogy of building a fancy house on a bad foundation. It's kinda what we're doing here as it relates to the economics around healthcare. I think Kent Boucher (46:11.916) So well, a logi a logical progression for a lot of people has been and nations. Well, and let's just let's just nationalize our healthcare. Let's it let's have it be government provided so everyone pays into you know, socialistic healthcare, right? Yeah. And I've seen people from those countries comment, yeah, this is the greatest thing, you don't understand how it works. Then I've also heard the other side. Kevin Kincaid (46:43.724) You know who says it's the greatest? Kent Boucher (46:45.462) Yeah, I I wanna know your opinion on it. Does does the healthy people? The healthy Kevin Kincaid (46:48.032) Healthy people. Healthy people. If you need services, you don't hear this was great. You had to you know, like my Canadian friends that would say, Boy, we got it nailed, you know, this kind of everybody has this same level of care and I'm like, Well, A, I know that not to be true because if you have the means in Canada, where do you come for your health care when you really need something? Kent Boucher (46:58.306) Yeah. Our neighbors. Yeah. Kevin Kincaid (47:17.856) Not Canada, become the United States. Interesting. And so because the waiting is too long. So like and to kind of give you an example of like a model that that I d I have I have thought how could we get there? But the greatest healthcare system that I've ever seen was military medicine. Why? Military medicine has absolutely zero perverse financial incentives to withhold something or to give you more than you need. Everybody got what they needed when they needed it because you had one one mission and that was to keep your your fighting force mission ready. Yeah. You gotta keep in other words Kent Boucher (48:04.876) You are you are as a soldier, you are a tool in the Kevin Kincaid (48:07.988) There was no economic incentive to withhold care or to do more so you could get paid more. It was it was a now, then you're gonna argue, but you didn't have the homeless and indigent, you didn't have you know, like the elderly population that should things like that. Yes. Totally understand that. But the when when those when those economic incentives were not just diminished, they were out of the system, it became a very effective way to provide care because you for instance if a hospital in you know central Iowa starts providing new kind of surgical services that's really popular with patients and starts drawing people to that facility, the facilities around them go, boy, I better I'm gonna have to buy that piece of equipment now. I've got to do that service. And so you're increasing the cost, you're duplicating services because it's it's kind of how we're set up is that there's still that you know, you're you're in that economic cycle of competition. Yeah. And you know, obviously competition, the VA is an example of something where I've s I've received as for myself received some of the best care that I've ever received in the VA health system. It gets trashed all the time, some of it qu wildly unfair. But there's there's an echo there's a they don't have some of the economic incentives about well, hey, I'm gonna stay late tonight because you know, because we want to get more patients in and those sorts of things. So there are some trade offs with these government sponsored programs or, you know, this universal healthcare. We've heard the term single payer. Mm-hmm. My goodness, that would be Kevin Kincaid (50:23.244) the burdens off what we'd go through to get paid if there was only one payer, and that'd obviously probably be the federal government. we wouldn't have all these people that have to just chase down all the rules and denials and all the special protocols that each insurance company is asking for if there was just a single payer, there there would be some streamlining that would have amazing accomplishments. But what if that single payer decides, well, I'm gonna pay you less than what it I you know, like that's the s scary aspect. So there's nobody has really figured out the exact right solution. Yeah. But what we're currently doing is basically setting up knowingly that the system underpays, but we're going to set up these quote unquote temporary. No. payment schemes, kick that can down the road and eventually we'll get to the wall. And that wall is gonna happen in my lifetime. So certainly your lifetime. Nicolas Lirio (51:29.462) Wow. Do what so when Well I wanna I wanna I wanna talk Kent Boucher (51:34.092) Well let's ask that. What happens when we hit the wall? Kevin Kincaid (51:37.548) Well, I mean there is an argument of saying that how how can you make systematic and fundamental changes on how something works when most people are happy? Mm-hmm. It's hard to do. When the system is in complete failure, that's when you can make changes. Yeah. you know, just think about Kent Boucher (51:59.672) And then at that point it's reaction. Kent Boucher (52:05.838) That's Iowa and water quality, right? Kevin Kincaid (52:07.158) Right you know, like in a you know, how businesses are run, you know, Sarbanes Oxley came about, well, Enron, I believe, all the you know, like this massive you know, we had our two thousand eight you know, real estate collapse. We had you know, the Great Depression. A lot of things changed because of that. It it put the put the you know, just it's just terrible to think that you have to get there to get people prepared to do something different. But it i I I understand from a a policymaker's perspective, you know, how do you go out and sell sell this to the people who are basically your bosses that put you in, you know, hey, I know you like what you got, but in ten years this is gonna be a problem. So I wanna make some changes you might not like, but trust me it's for the good for that's a hard conversation to have Nicolas Lirio (53:05.782) Back to that that kids with the marshmallow we talked about on the podcast. Kevin Kincaid (53:09.006) Cast. Kent Boucher (53:09.728) Well, I I I'd just be curious. I know I'm dominating the questions here, Nick, I'm sorry. if you could if you could and I'm I'm not asking to totally restructure all of how we fund our our our country's medicine, but if what would be some logical changes like for me when they were re reevaluating overall, I I wasn't a big fan of the big beautiful bill for a lot of different reasons. One of the things that I was I was I gotta be very careful how I say this. One one of the ways or one of the things that I was open to consideration was not doing away with Snap, but saying, Yeah, and and I think Iowa even did some stuff on the state side of this as well. you can't buy Coke with with your snap. credits. You can't you can't buy candy bars, you can't buy, you know, zebra cakes. it's meant to be for the the stuff that keeps you and your family healthy and and fueled with with proper nutrition. That to me is a that's a good you're not taking away your the family's not going to starve. Yes, it's it it's thinks that now poor a poor mom can't get her a poor single mom can't get her kid a a candy bar and make his day. But at some point the candy bar is a luxury item and and Nicolas Lirio (54:43.884) And they're a net negative on humanity. Kent Boucher (54:46.744) Candy bar? yeah. Yeah, you better be careful with how you say that, not the people. Nicolas Lirio (54:51.212) No, yeah, so the the the candy bar, yeah. Kent Boucher (54:53.132) Yeah. But so so to me that is a common sense adjustment that helps make that money you can maybe make a dollar go further for the person's health, which is what we're trying to do. It's a it's a nutrition program. Are there things like that that you could see happening with like maybe you gotta have a BMI within this window or your I mean, they do that for life insurance. Your cholesterol has to be this level, your you're I mean, you can't be pre diabetic or your premium goes significantly up. Is there stuff like that you think would would help? Or what do you think? Kevin Kincaid (55:27.714) Yeah. Kevin Kincaid (55:31.99) We've dabbled in in that in that space, but the the problem is at the at the pr on the provider side. so like for for instance, you know, let's say if if people had a healthier lifestyle, I'd have less heart attacks come into our ER. Okay, true. But heart attacks are still gonna happen. Right and and so on the provider side we are going to take care of people how they come to us, period. Mm-hmm. Now we would we would help them understand maybe be more involved in education, maybe more involved in s with schools and nutrition information and all these kinds of things and and but It's gonna be super hard for us to you know, say, Well, because of the lifestyle choices that you chose, you you drank too much alcohol and now you have liver cancer and you don't get the same chemo that the person Right you know, do you see where like Kent Boucher (56:51.85) Well it puts all the pressure on the provider. Kevin Kincaid (56:53.858) Yeah, and w we just don't do that. We we take care of people as they come to us. Now, we we do participate and and I also with the American Hospital Association work on policy boards for nationwide policy ideas. Like one of the things that's happening from a policy perspective that I think is crazy interesting is the health policy implication of all the GLP medications that are running around now. And so that is creating a health policy thing that we got to kind of wrestle with. Now, if the insurance carriers or you know there was some sort of governmental mandate around those sorts of things, you know, we would have to live within those parameters. But we just live in a world in the hospital community, you know, the physicians and providers that are here, there's just no differentiation of how you got to where you are. We just take care of you. Yeah. But on from a public policy perspective of what you're saying is that if we could reduce Iowa's BMI, we we would use less health care. Nicolas Lirio (58:11.64) Yeah, I heard a doctor on maybe diary of a CEO. Kent Boucher (58:16.974) I thought it was Doctor Oz you were watching. Kevin Kincaid (58:18.986) Shot. Nicolas Lirio (58:19.662) It was a great show. I guess he's not he's not doing his thing anymore. He's over in the the administrative building. But that they said that is in our lifetime gonna be the greatest lifetime expectancy technology change. because the truth is when you're overweight, you put a lot of stress on your body or even a little bit of stress on your body in a hundred different ways. And over the course of 40 years, that takes a toll on your body and can't handle it. And that doesn't happen every single time, but it is like one of the biggest root causes of so many of the things we deal with. I interviewed Dr. Haynes, and this is he was the one telling me this. Yeah, if we if we could just control how much we ate and how many calories we intook, that would be the even more than exercise, which he said was a big deal. that would alleviate a ton of the sickness. Kevin Kincaid (59:16.322) That's where the GLP discussion comes into place because these medications don't come with nothing comes without it with nothing's completely void of downside. Yeah you know, there are downsides with but when I talk to these physicians that are on this policy group with me and they're talking about their large panels with thousands of patients, and all of a sudden those that are on GLPs are like Not only did they lose weight, all of a sudden they're like, wait a minute, this group doesn't have near as much liver disease, cardiac disease, dementia, depression, suicide, yada yada yada. And so they're seeing this major change by carrying around less weight that implicates a lot of things across our life. And they're like, but the problem is the only people that are taking those medications are the ones that can afford those. Yeah. It's becoming Yeah, there's this it but anyway, it's but technology, new medications, just kind of there's there's a lot of bright spots in the world. Of course, you know, I talk about the gloom and doom and gloom of of of Nicolas Lirio (01:00:19.202) and fifty bucks a month or something. Kevin Kincaid (01:00:39.682) you know, the economics around care, but I still get that. you know, I think about the time that you know, when when kids are gonna learn you know you know how they cu you know, used to treat cancer back in the day. They gave people these medications that were essentially poisons or you know, they used radiation to you know, like what we do now to you know, preserve life. there will be a day when we don't do that. 'Cause we will have figured this out. And you know, and and the new technologies, the new high powered computer systems making treatment protocols instead of specific or just generally speaking for a general population being able to do treatment protocols that are very specific to you s individually and just how much better that works. All these things are gonna be making us better. healthier. but it's it it hits this this thing of how how do you how do you pay for that and or how do you make that available to everyone. Nicolas Lirio (01:01:49.218) Yeah. The pharma, so that one of the big things I've heard, it's talked about a lot really in the past couple of years, but for years, is the United States pays more for its medicine to the pharma companies who develop it than other countries, right? is that true? Should are are people in the United States getting raked over the coals on pharma prices, or is it just standard, they're just cost plus or they're they're playing the market well enough or Kevin Kincaid (01:02:21.078) I you know, I when you take a complex problem like drug costs and you apply a simplistic answer such as big pharma's greedy and we're gonna rip off Americans to s you know, take care of our greed, I I think you're you're always missing something. You know, for instance, you know, like I would want to better understand I see here inside the medical center every day miracles, I mean miracles happening because of big pharma that we like to trash. They are they are creating medications that are keeping our loved ones alive. They are doing that. The people that develop those drugs, designed those drugs, did all the research. I th I think they need paid. And who's going to do that? you know, like is the r it should the rest of the world help s subsidize that? There's also been this idea of no okay, why what what if these great thinkers in in pharma decide, you know what, we're not gonna be do doing this in the United States. We're gonna go somewhere else. We're gonna set up shop in China or Taiwan or wherever else. Do you wanna lose that? You wanna you know lose that, you know, that intellectual so anyway, my my whole point is I'm not a big fan of big pharma and a lot of the things that I have to deal with, you know, I just see my goodness, these expenses are runaway and things like that. But I also give myself pause and say, remember that person you just said hello to in the h hallway? They are not here today without big pharma. Yeah. So like how how do we come to Nicolas Lirio (01:04:18.284) So no blanket statements. That is it is a nuance. And I really appreciate that. That's one of my favorite things about you is is you put on a scale, there's almost almost never full weight on one side of an argument. There's stones on either side, and then we gotta figure out which side actually weighs more. But Kent Boucher (01:04:37.068) I got I got a question on the future here. You're talking about, you know, especially and that's been one of the things that's been touted why we need AI that's gonna it's gonna solve complex medical problems that have been stumping us for decades. I've also heard that this was a few years ago, there was this phrase I haven't heard it in a while, so maybe the projection is dead now. But they they used to say if you're in your thirties or younger right now, you need to be preparing to live to be one hundred and twenty years old. And That sounds great, right? But I used to be a teacher in Illinois and I was a part of the Illinois teachers pension. T R S is what they call it, teacher teacher retirement system, I think is what it was. And there's one day they had a TRS rep come to the school and talk to us about our pensions. And she said, you know, she just had like some interesting trivia about TRS. And, you know, one of them was like, guess how old the oldest? TRS member is. And I wanna say this this woman was one hundred and four years old. She was still drawing a pension from Illinois TRS. And and I think I did the math and she had been retired twice as long as she'd been working, paying into it. And if if humans are going to because of medical advancement, that's and I mean That's happened w when I I mean, even when I was a kid, you know, if you penicill you sa yeah, right. You saw somebody in their eighties, that was that was pretty old, you know. A lot of people when they start hitting their sixties, you started, you know, it could be any day for grandpa, you know, and and that's drastically changed. I our our overall life expectancy really hasn't altered much since I was a kid. I think it what is it, seventy four for males and seventy six for females, I think, something like that. Kevin Kincaid (01:06:37.89) A couple of drops and which is shocking. Kent Boucher (01:06:40.76) Which I I I have a great theory on how we should use that for our term lim determining our term limits for our politicians. But medium theory. You didn't give it enough credit, Rice. But the point being if we end up in that TRS situation where people are are now so not I think we have a declining birth rate overall for a lot of our a lot of the the world. But if people are living longer, then our population could for at least a a while yet continue to expand just the number of people that are still alive on the planet. And we're having to insure all these people. Nicolas Lirio (01:07:20.962) But they're not more work years. Right. You got Kent Boucher (01:07:23.432) And teens. And and probably more more dependent on things like Medicaid. Kevin Kincaid (01:07:28.096) Yeah. I th you know, yeah, well yeah, it's that's an interesting question because the anything is possible. I mean, yesterday I was traveling a little bit and I was listening to some of the news stuff that Neuralink is doing. Yeah. Very soon the blind will see. Yeah. I I mean like I never would have ever imagined Kent Boucher (01:07:30.84) Is that possible? Kevin Kincaid (01:07:56.248) There's a there's a world that somebody's figuring that out for maybe folks that have never had eyesight, you know, to be able to see. And and so I think what I and I'm so interested in this that I volunteered to chair the state of Iowa, Iowa Hospital Association's innovation council. So This is where we're bringing in experts around the country to tell us, you know, like with AI, like how to deploy it properly, have the policies and guardrails around it. I'm just so fascinated by around what you're talking about. But honestly, I think where the emphasis is going to be is not going to be in quantity of years, it's gonna be in quality of years. And Doctor Haynes and I were joking, I showed him what I wanted my life curve to be. Yeah. You know, like this say this is my ax you know, axis for activity. I want it to go up and flatten out and go flat and then I want it to hit a cliff and fall in. Kent Boucher (01:09:08.235) Yeah. Kevin Kincaid (01:09:11.552) Yeah. I don't want no decline over twenty-five years. I you know, I said that so as my personal physician I need you to make this happen. And yeah, he got a kick out of that. But I I mean in all honesty, you know, this I need you to make this happen. Yeah. Yeah, I don't don't drag this out. But but I I think that our advancements are really around there that you know, Nicolas Lirio (01:09:29.398) Yeah. Kevin Kincaid (01:09:41.214) And the economics of what you're saying about the retirement plan that you were discussing is that I I can easily see that you know, maybe my son's generation or the generation that follows him, they will be laughing, going, Can you believe that people quit working at sixty-two? Yeah. Like that that's I I don't think that's realistic that that i you know, people will stop working in their sixties. I think people will hopefully with technology people will be involved in more meaningful work to them. So you know, the technology will take, you know, some of those ho drum, you know, mont mentally unhealthy jobs away and then people can do meaningful work that to them. you know, that's kind of a you know a pie in the sky view. But honestly I think people will work longer and have higher quality years because of technology and advancements in healthcare. Nicolas Lirio (01:10:43.374) Got a this story. So I have a friend. I'm gonna leave his name out, but he's very open about the fact that he has autism and he's happy to talk about it. Very smart, very blunt. and we just happen to run into each other at high V, checking out at the same time. Hey, how's it going? We're talking about it. And then we both turn our attention to the cashier, a person who is approaching retirement age, maybe retirement age. and they s they were very concerned about social security. They that like. We asked how they were doing. They they brought it up. And they said, Can you believe they'd taken that away from us? We we've been paying into it for forty or fifty years. and my friend next to me who has autism, and whatever part of our brain has a filter, he doesn't have that. he goes, Yeah, it's just a shame they spent all that money already. And like no no remor no like kindness or soft landing, like, yeah, it's a bummer, all that money's gone. You know, it's just like but that that's the reality. She's talking from a social, what's fair, what's that's great, you know? And and as an employer, I could I could tell the employees, hey, it's fair to pay you $40 an hour. I have $28 an hour. So that's a that's a real reality. I want to make happen. I want to have money for you in Medicaid. I want to be able to help pay for your health care. I think that incentives are important, but I want to be able to be there. I want to catch the the people in the lowest economic ranking in the society I want to have a net for them. I want all of those things. The money's not necessarily there. What do we do with that? Kevin Kincaid (01:12:19.234) Yeah. So a personal opinion that I'll share, and that's all it is is a personal opinion because it's wildly controversial. But if you go back, I've seen the math on it, I wouldn't be able to recite it, but it'd be interesting if you go back and look at do you remember George Bush when he made his his one of his major initiatives, administrative initiatives, was to privatize social security. Yeah. And he got trashed on it. There are people that went back and looked at the math. What if that would have passed back in George Bush's tenure, what retirees would have to do. a senior, right? Yeah. and what retirees would have compared to their s you know, it's shocking. It is Absolutely shocking. And you know, and I happen to be of the belief that we cheated those people out of that. We cheated these seniors out of that, that opportunity to take place in the take part in the you know, the the greatest economy in the world and you know, we have our ups and downs, but they would have been so far ahead ahead. But people were so scared of what if what if Kent Boucher (01:13:41.086) It goes back to people are people are happy with what's worked. Kevin Kincaid (01:13:43.922) Yeah, and and so just put a little bit more money into it. And so what what I f in and back to our healthcare changes that, you know, at some point we're going to have to have wholesale changes in how things work because there's there's not going to be enough people in this country, and I'll argue that we've already reached that point. There's not enough people today working, paying into the system for those that are taking out of the system. Like my grandpa said, he, you know, he would say we have more people riding in the wagon than pulling the wagon. Yeah. and and that's kinda what's happening here. And the reality is if you're riding in the wagon, you have a legit argument to go, look, man, I polled. I polled for a long time. It's my turn to ride. but at some point you're gonna have to make that cut of No, get out of that wagon, you gotta start polling again. And and so People aren't gonna like that and it's gonna be wildly unpopular and you know, from a policymaker's perspective, I don't know how they Nicolas Lirio (01:14:49.688) Easier to like raise just raise social security by one year, like one age year. Raise it one year every three years. You know what I mean? And and then you could get three or four years added to it over the next fifteen years and it would be Kent Boucher (01:15:06.274) Yeah, I think I think an an underrated method for doing that is grandfathering. You know what I mean? Yeah. When when you say, and actually this happened to me again in the TRS, they I was a what would they call it? Group two or something like that. So everyone that w had been working for a certain number of years, you were a group one TRS, you could retire. I think it was like fifty seven. fifty seven or fifty eight if you as long as you start at twenty two fresh out of college and did your your yeah thirty five years. When when my group started it went to thirty eight years. And and so there was a grandfathering, but you could complain, but you're new here. You're the this is the new rule. And I think that to do something like that you wouldn't want to do it to people who are fifty and say, guess what, you gotta work an extra year. You know what I mean? They've been most people have been hating their job for the past thirty at that point and they they're they're they're counting down the days. But if you did it to peop you know, people just entering into the the job market now. Kevin Kincaid (01:16:15.722) I mean correct itself. There's no there's no policy around fixing that. But I mean, I think just recently they had to move down the you know the Medicare Trust Fund, you know, by another couple years or so. They I think we're at twenty thirty-three without fundamental changes, it's there's there's no more money for that. and so I think I think the younger generation Well, I don't know, I ask you guys, but do you honestly believe that you're gonna be able to draw a social security ch check at sixty two? Do you think that's gonna be around for you? Kent Boucher (01:16:54.924) Yeah, that th that is I I mean, we do so many band aid fixes to things that that's the only reason why I I think that it is possible. Right now, looking at the math, I don't think it's possible. Kevin Kincaid (01:16:56.74) Or should it Nicolas Lirio (01:17:08.462) Pensions don't math, and you know that because every single company in the United States ripped them out of their books because they realized, these don't math. But the problem was that government level pensions, they couldn't just rip them out because then they'd get voted out of there because those people want their pensions. Now companies change it to four one K's, And I am a big fan of I don't even know what they call it, but having like a public trust bank account or whatever where each kid when they're born gets a thousand dollars S P five hundred so that people are incentivized to see the economy grow. But I the one of the things that I think we should get back to doing, I think this is a common sense thing, is and I'm a I'm a big anti shame person. Like I think people hide in shame in all sorts of areas in their life and I talked through that with my friends, Kent is would attest to that. But I think we should shame schlucks. schlucks are well a abled bodied I did. abled bodied, perfectly capable people that are that are drawing significantly more off of society than they're giving. You know, think of people like young men, twenty two, twenty three, twenty four year old men. Kent Boucher (01:18:18.114) Think you just made up a word. Yeah. Nicolas Lirio (01:18:33.856) Still living with their parents. Nothing wrong with that, but no direction. And they're maybe working a job. I know that sounds stupid. I can list four off the top of my head right now, and I don't even hang out with 22 year olds. You know what I mean? I I can list four. I'm like, you're able, you're able bodied. You know, what is going on here? I think we need to shame Schlucks. And then I had a a foreign exchange student when I was in high school, she came from Denmark. Kent Boucher (01:18:56.888) Where does the word schluck even come from? Trying to think of what it's a derivative. Schmuck Nicolas Lirio (01:19:00.566) It's a great word. I mean if it's not real, then we d I'm trademarking schluck. And and you I'm not saying we need to be working 70 hours a week, blah blah blah. The Asian side of my family, they're like, look, you do your time. And and to our culture on on that side of the family, your time is sixty, seventy hour weeks for forty years. That is it that is just what is expected. They're like, But work life balance, what are you talking about? You know, and now whether that's right or wrong. That's not what I'm talking about. I'm just talking about like generally adding to society. Or contribute. Yeah. Which is where my my foreign exchange student, good friend in high school, she came from Denmark. And when we were all talking about going off to college, this phrase came out of her mouth all the time. And it was very weird to me at the time. For society. Well, I've been thinking about for society, the better thing is, or I'm wanting to do this for society, or I think that would be bad for society. A lot of her decisions were based on her neighbors. What would be good for now it wasn't fully that way, you know, she'd had some say and she did what she wanted to do, but Kent Boucher (01:20:04.224) Somebody talked about that around two thousand years ago. Yeah. Nicolas Lirio (01:20:07.116) Yeah. The love your neighbors. Ken actually you came up with that phrase just the other Kent Boucher (01:20:11.782) did I did I come up with that? No. Write it down somewhere. Nicolas Lirio (01:20:13.578) but I should it it's it's wear a robe. Yeah. The the cultural issue here I think is is kind of a big deal. If if our generation can't look at can't look at social security and Medicaid as a problem together and we just go, Well, better be for me my my turn, you know, when I get there. We're screwed, and I have this term that I've been bouncing around in my head. I call it reasonable selfishness. It's someone choosing some selfish, but it's it's reasonable. Well look, everybody else is drawn. Everybody else is getting a new roof right now. Why can't I? You know, I o I know I only had a couple dents out of hail damage, but you know, I I don't know. I've I've been paying for twelve years. I think it's about time you know, it's this reasonable selfishness that when you add it across three hundred million people, it becomes a very greedy selfish issue. And now all of a sudden there's all these fingers in Medicaid and we can't actually pay the doctors enough up front with the the initial bill. But I wanna two more things we I wanna chat with you about before we take off today. first I wanna talk about Not necessarily I don't want you to have to announce what you would do at the hospital, but what are the what are CEOs of rural hospitals gonna look at first if this one point five billion dollars ceases? Like what what areas of the hospital and their clinics do they start saying, Okay, this is where the cuts are gonna happen? Kevin Kincaid (01:21:46.782) They they're already doing it. Nicolas Lirio (01:21:50.592) Okay, what what what are the first services going that Kevin Kincaid (01:21:54.412) the least profitable. Okay. And so where does that become very apparent to people? O B programs are already under huge stress. Wow. Kent Boucher (01:22:07.554) Okay. And and yeah, I want to camp on that for a second. I I didn't realize this and I should because my wife is an O B nurse. Iowa is considered to be a place where there's a real shortage of O B care. Is that true? Kevin Kincaid (01:22:24.755) It's it's it that is true and it's getting marketably worse. Kent Boucher (01:22:29.902) Mm-hmm. And this is this is gonna make Kevin Kincaid (01:22:33.426) This is gonna make that make it much worse. More difficult. Yeah. you know, when I said earlier that hey, I think you should have access to the same level of care regardless of your zip code. Right now I'd have to say, well, except for OB. because I know that's not true. Because we have OB OBD what we refer to as OB deserts across the state. Wow. you know, Between Omaha and Des Moines, there's there's just a few facilities that still deliver babies. And if those organizations became un under stress, you that's that's a lot of distance that's gonna equate to some bad outcomes. That's just one example. Now there's all kinds of things that hospitals do. it's kind of a a weird business to be in, you know. First off nobody wants what we're selling. You know, nobody wants to be here. So that kind of makes it a little bit different. Yeah. And then when I'll I'll have somebody say, Hey Kevin, you know, I think your hospital will do way better if you would just run it like a business. Mm-hmm. And I was like, well I have a business degree and I know how to do that. But I promise you you won't like it. Mm-hmm. Because I provide a lot of services that are bad business. You know, like I do not see any gas pumps around town for the poor people. No. I mean that you that doesn't exist, but we provide services to everyone regardless of their ability to pay. And when people say those things, you know, like, hey, I mean there's some truth in what they say, you know, there's some things that should be better buttoned up on the economic side and how the finances work. Because if you've if you've had a complicated health situation going on with you or a loved one, I can promise you, as your bills come rolling in, you just had this massive what the heck is this? No, bills coming in untimely and they're hard to understand and they're coming from every direction. I know that needs Kevin Kincaid (01:24:57.036) That has got to change. But there's a lot of things that go into, you know, why it is as in in a lot of things. But but that whole concept of why don't you run that hospital like a business? Mm-hmm. I can and you won't like it. Yeah. there, you know, like the or the city. Well, they're not gonna be if they they do that, there's no ambulance services. Yeah. You're not gonna have an ambulance if you wanna run it like a business. Yeah. We're not gonna have an ER. We're not gonna have you know, a lot of the primary care access and what we would be is what you see in a lot of metropolitan areas. If you wanted me to run this like a business, you'd be able to get your labs drawn here, X rays and surgery. Wow. Nicolas Lirio (01:25:43.436) Yeah. Yeah, my wife and I spent way too much time in an ER last March through June. And we were in are there three major hospitals or two in Des Moines? I think two. Yeah, two. We were in both of those miserable. I mean the wait the waiting room was huge. The it was just people were screaming everywhere and Kevin Kincaid (01:26:01.424) two, the big Nicolas Lirio (01:26:12.972) There's ER's not there's not money in ER, you know, and and it's interesting to see, you know, but then at one point, we had to go get some scans in a different part of the hospital. And it was like the most pleasant, wonderful part of the hospital because it's easy to put money where you can make money. You know, it's hard to justify spending a bunch of money on an ER where it's just a pick. Kevin Kincaid (01:26:35.43) Yeah, like for you know, like one of the examples I'm sure I've told you this that if you have a heart attack or let's say a bad car accident and you got orthopedic fractures all over you, I'll have a multi million dollar h helicopter sitting here in minutes and you will be on the operating table within minutes and there are financial penalties if I don't get that done. It is a machine. when you are hurt like that. you come in in a mental health crisis, you'd be here for days, weeks. You'll rarely get the exact surfaces that you need, you know, and and can be just as serious as, you know, people coming in that are suicidal. can be just as serious as a bad orthopedic fracture. and And that's just an example of like something that does not have the economic engine around it like a heart attack does. Do we we have we have hospitals that specialize in cardiac care from trying to prevent heart attacks and tracking you and doing screenings and then when you if w when people do have a heart attack, the best and brightest there to take care of you and step down units so you can get back to your job. Now imagine mental health. You don't have any of that. Yeah. Or very little of that. And so those are those those are just some of those systemic problems that we've been working on for a long time, but the economics of it just don't support it. Mm-hmm. Kent Boucher (01:28:16.226) Yeah. Nicolas Lirio (01:28:17.336) The other thing I I wanted to talk about before we take off is is talent. I was just at the eye doctor, Dr. Mosdam and Dr. Mosdam, and they had a third wing built out their clinic because they had another eye doctor and then I I believe she she stepped down for something. It w it was like it was all good, but she stepped down. Well now they have the now they want to fill this with another eye doctor, right? And they can't. Because i doctors are capped on how much they can get paid because of insurance. Sure. All right. Which which I understand the pros of it. Now it now I'm about to explain the cons. So the one incentive of moving to rural Iowa when you aren't from rural Iowa is, well, maybe you get paid more there. Maybe you could go and pay that doctor more. Well, they can't because they can't get paid from their patients more because of insurance. So now they have no negotiating. leverage with anyone, why would anybody come to Knoxville, Iowa, unless they're from here, why would anybody come here when they could be in Des Moines with all the amenities? When they could be at Iowa City, when they could be in Minnesota or, you know, twenty minutes outside of Des Moines, on one of those cute little towns like Carlisle or something. Why would they come all the way here? Now I think there are a lot of draws to Knoxville, but they're they're harder to explain and they're harder to weigh in. It took My wife about a year. Now she loves it. She's like, I can't imagine why someone would live in a big city now that I'm here. and and so, but it takes a while. It's hard to negotiate that over a table. And so pulling in the talent of doctors and and is it secondary care provider like PAs and and nurse practitioners becomes very difficult. And I guess I don't what's that gonna look like for r what what direction is that trending? Is there any Is there any positive outlook on that changing? What what's going on? Kevin Kincaid (01:30:11.598) well it's and and and I'm gonna talk about rural America. It's trending in a horrible direction and there is nothing on the horizon that says it's gonna get better. Wow. Yeah, and that uplifting. But on the flip side of that is technology's going to be a huge help, giving you access to providers when you need it. Nicolas Lirio (01:30:23.49) That was awesome. Kent Boucher (01:30:40.108) Like Kevin Kincaid (01:30:40.958) Yeah, teleh telehealth is gonna keep getting better, more of this virtual medicine. you know, and then you know, because rural America would not have health care without PAs and nurse practitioners. They're crucial to the system, but they have to be appropriately deployed. And and so how do they get that medical backup? MDDO backup when they need it. A lot of times that's going to come via technology. So that's going to our demands for doctors, nurses, technologists is going to far exceed the available people to do it. So we have to come up with different solutions because you cannot use the model of, well, I'm just always going to have this number of nurses to take care of our community. I know for a fact it's going to be harder to maintain that number. So what are you going to do? What am I going to do to make investments in the right technology? And so we've done that. you know, like one of the things that I like to, you know, basically do is that I know there's a healthcare shortage in rural America. and I understand that and I want to work on the solutions, but here in Knoxville I refuse to participate. So that's kind of kind of how that's unfolded for us, you know, trying some different things before other people did. I would say we were one of the first facilities that I know of that really took on new inpatient care models. we made big investments in lifestyle that w family work life balance, you know, when I talk to a lot of the, you know, physicians from a generation ago, you know, and you talk about, well, you know, what what regrets do you have? I I absolutely love this profession of being a doctor. It was my calling in life. My only regret is I was an absent father. I was an absent mother. And I just kind of refuse to think that that's how it has to be. Yeah. And so we worked on that and we invested in that. And Kevin Kincaid (01:33:05.186) You know, a lot of things I can't take credit for. We had some great recruiting wins and kind of like that snowball rolling down the hill, good providers want to work more than anything with other good providers. Yeah. And so that's like this self fulfilling prophecy of, you know, hey, these folks that are in residency, where should I go work? I'm thinking about maybe staying in rural Iowa. Well you know who's at Knoxville, blah, blah, blah. And I know them and I've heard about them. And so it's just been a a a really good strategy for us. And I don't know, probably there's some element of luck in there that we were able to pull that off. But I know that our our talent access to physicians and mid-level providers, I would stack them up against anybody. I mean anybody. That's how good this team is. and but that's not the norm at all. Kent Boucher (01:34:18.806) Yeah, so something that really came out of COVID and I I'm sure it existed beforehand, but this is talking from my understanding with my wife being a nurse and she was she was not just in this area, we we lived out in the Quad City area and so she was at one of the bigger hospitals there and they would get a lot of traveler nurses to fill out the staff for for these hospitals and During COVID, you just saw this like new wave of all these nurses that were leaving permanent jobs to take on these traveling contracts, to to staff all around the country. And I Nicolas Lirio (01:35:07.79) Way more money. Like it was it was it was like fifty or sixty percent pay increase. Kevin Kincaid (01:35:13.313) I Kent Boucher (01:35:13.46) I in in the most extreme cases, yeah. Kevin Kincaid (01:35:15.896) Well yeah, no for sure. I know of lots of examples by name where nurses gave up their job in Des Moines and the next day went to work at the same job on the same floor in the same unit. Kent Boucher (01:35:29.528) Wow, just as a traveler. I gotta imagine that is not good for the work environment of the hospital itself or the health system. But also that's gotta be hard on communities where you have these good paying, you know, upper middle class level jobs that now technically are transient. And now if they're anchored down by they got kids in school, their spouse works at local company that helps for sure. But even then, you know, she's had friends who husband and kids are three hours away doing their thing three or four days a week while they're out here working, you know? And I imagine that even across I had a friend from college who who did this. He would live in different states. You know, he'd go you go all around the Southwest living in all these different states. He'd get a get a short term lease on an apart on an apartment, sign an eight week, twelve week contract, maybe renew if you really liked it there and then he'd pick up and leave and he'd go somewhere else. I mean I just can't imagine that that I understand the need. You gotta have nurses. You can't you can't can't staff the hospital without But is it I mean, is there a way that hospitals can get out of that? It just seems like a a a you know, you're putting the fire out with Kevin Kincaid (01:36:55.818) Well they they they have for the most part and there are implications with that of course. So if you use COVID as the example, the pandemic, a better way to put that is that hos so like there there wasn't even any I didn't even know of any patients, COVID positive patients in our community, yet my hospital was shut. down. Yeah. Could not provide services that fund everything except for like emergency services. And a lot of people left the profession and and then then as the wave came Nobody came back. They're not enough. And then this, hey, traveler now travelers are a necessary element of the healthcare system. But it can't be when it became your primary workforce that upset the Apple cart. That's not how things work. It's not sustainable. So essentially what large hospital systems did, they just said, Stop. We're not doing it. Not gonna do it. So when these traveler contracts are up, we're not renewing them. Mm-hmm. So what's the reality? What's the implication of that? They close beds, they close wings. And so what's the downstream effect of that? I have a patient here in Knoxville that exceeds our clinical capabilities of being able to take care of. Hey, I need to transfer them to Des Moines. No. Mm mm. During the pandemic, we'd we'd ac actually I think our furthest example, I can remember we moved somebody to Houston, Texas. Wow. And it was like because there was no there there there weren't any beds open. And so what that really indicated to myself is that you know, it's a whole other topic, but I'm just saying that it it shed a light on how fragile the healthcare system is. Mm-hmm. And also Kevin Kincaid (01:39:05.474) We have kind of been running like a business from the perspective of we don't keep excess capacity. Like in other words, I have enough staff here at the Knoxville Hospital and Clinics to take care of our community on normal days. I am not staffed for the worst case scenario where a third of our community gets sick. Not pa I w I w I couldn't do it. You know, so you know, like there's not any really built in buffer in the healthcare system. Every hospital is set up for kinda normals. But when you have a situation, if we were to have another pandemic, let's say something that was you know, clinically more significant than COVID, we're in real big trouble because we don't even have the capacity that we had previous to the other the pr previous pandemic. So you know. And all of this is built on the fact that there's not enough funding, there's not enough economics in that, but also I'm not casting stones at this because you look at what we spend in healthcare in this country and it is a huge dollar amount that our country is shouldering. Yet you have people like me going, Well, it's not enough. Well The really smart kids in the room are gonna have to redesign this. Mm-hmm. Man. Nicolas Lirio (01:40:38.946) Well, we really, really appreciate you joining us and and and we didn't really get into this and and we don't need to, but for everyone listening, Kevin's like not just a big deal in Knoxville and and he he he is a leader in how hospital policy gets made. He is pinged by people that are a big deal and and part of that is you're a great leader. But when you came to Knoxville, there was like five days of cash in the bank. That means like every day they operate, they only had enough cash to finish the week out and they hope to get more cash before the end of the week. And he tot he totally turned that around. Knoxville Hospital was on the verge of closing down. And now it is ten percent of the staff the of the employees in Knoxville work for Knoxville Hospital. Or the work ten percent of the workforce is here at Knoxville Hospital. And it's a big deal. I I am really grateful for you personally, but even just on a larger spectrum, I understand how big a deal rural hospitals are. Kevin Kincaid (01:41:32.91) No, I appreciate you saying that. but the one thing that that I always like to also remind myself is that and and I appreciate those comments, but certainly worked hard and had a lot of sleepless nights, but nobody comes here except on occasion like you. Nobody comes here to the hospital to see me. And I keep that in mind all the time, is that it is our staff, the physicians our mid level providers, those are the hot rods around here that you know, people wanna come see when they're in trouble. They're scared, they're hurt, they're sick. They're not coming here to see me. I just try to create the environment where they can do their thing. But we're so blessed to have this team that we have here that no, like I've been in healthcare you know, pretty much my whole life ex Minus a couple of little submarine jaunts, but my entire adult life has has been you know, healthcare. So I I basically can see and know who are the best providers in the state, who would I send my loved ones to? And they're right here. Mm-hmm. Man. And so that's that's what makes this a great place, great job. Yeah. Kent Boucher (01:42:56.099) Well, Nicolas Lirio (01:42:56.61) We all know rural communities, they are I mean, they live and die by the leaders and and the people that live in And it takes all of us, just like conservation. Conservation happens just one mind at a time. Man, that was great. Kevin Kincaid (01:43:12.158) That was a great conversation.