While patients in some “universal care” countries like the United Kingdom endure long waits for certain health care procedures, many Americans avoid doctor visits altogether because of high deductibles, according to Clinton Foundation President Donna Shalala in a campus discussion about expectations for health care after the U.S. elections.

In the U.S. “it’s an invisible queue system,” Shalala said. “People who are putting off going to a specialist or going to a doctor because they don’t have money to pay that deductible. We have to overcome that.”

Watch the April 26 talk

Shalala, the Secretary of Health and Human Services during the Clinton administration, joined Professor Renée Landers, a onetime colleague and now director of Suffolk University Law School’s Health and Biomedical Law Concentration, for a discussion that ranged from the Flint water crisis to potential cuts in funding for Medicaid and Medicare.

Asked by Landers about health care insurance affordability, Shalala identified high deductibles as a significant trend.

“I think it’s the worst way of controlling costs,” she said. Employers are shifting costs onto their employees, she explained. Even if companies add on a free physical on the front end, they’re basically shifting their plans to catastrophic plans, reducing doctor visits.

Landers served as deputy general counsel at HHS under Shalala and as deputy assistant attorney general in the Office of Policy Development at the U.S. Department of Justice during the Clinton administration.

To get a sense of the direction on significant health care issues after the election, “watch Paul Ryan,” said Shalala. “He’s actually a friend of mine,” she said. “He’s very much in favor of premium supports for Medicare, that is, giving people some [financial] support for purchasing their Medicare rather than what they have now, which is a guarantee—an entitlement.”

Shalala said that Ryan is in favor of having the federal government provide lump sum grants to the states with specific caps on the total given to each state. The states would be responsible for making their own decisions about coverage.

“That’s what I would watch,” she said. “Don’t take your eye off the ball of Medicare and Medicaid, because those are the big cost items. That’s the trillion dollars in the health care system—and I don’t think they’re going to leave it alone.”

On the issue of public health crises like the lead in the water in Flint, Michigan, Shalala said that she sees a potential area of agreement between the Republicans and Democrats. Crumbling infrastructure is evident in low-income communities like Flint as well as higher-income spots like Manhattan, she said, “and pension systems have already indicated they would step in to buy bonds, so there is a political coalition that we can put together to start dealing with infrastructure.”

Landers asked Shalala about her views on a single-payer health care system. In such a system the government, rather than private insurers, pays for health care. “I happen to not particularly be a single-payer person, because of my understanding of the politics of it,” Shalala said.

As for “the public option,” through which citizens can purchase insurance plans through government programs like Medicaid or Medicare rather than private insurers, Shalala said, “I’m all for competition, but I’m not sure that the public component adds that competition. I’d probably add a [public] option, but let’s not add much more complexity.”