In the wings by chance . It i did. I can see them coming and there is a handwaving. Very good. Chris and lonnie, good to see you. I was afraid i would have to do a soliloquy or a monologue for an hour. That would have an something. Grab a chair. We are now going to have a debate. We will have a classical republican versus democratic debate. It seems to be the time to do such a thing. Repeal and replace in the wind in the wings. A polarized congress and a polarized nation. Would make sense to go invite a couple of representatives, from the left and the right, so in terms of format, let me provide introduction to the gentleman. Then we will allow each of you to make a statement to provide and then wetive will go ahead and talk. Immediately to my left, a couple of times, i believe. He made his mark in big ways in this city. The drafting of the Affordable Care act and the clinton administration. Aslknown and very much a d in democrat. You get to represent that in our polarized world. A fellow at the hoover , theation, and then mostly top three if not the first number one leading voice on the right in terms of health care reform. He was an adviser to the review campaign. We see his writings everywhere. The other a panel night and he is a good you that, why dont i join and to my left, chris, i will let you go first. Chris i will be happy to regale. I do feel i should go to the we are in the minority right now. , thanks torgy now republicans, which we appreciate. Democrats only too well when republicans do poorly and it is usually whenever divided amongst themselves. It is not because we are good at all. The occasional division and dysfunction only does one good thing for democrats, to camouflage hours. And there is much. Today, you are seeing i think uniquean extraordinarily time in a health care debate. We just had this election. Can talk about the polls and what was asked, but it is pretty significant there was no other issue that pulled as high inngst voter interests as health care by twentysomething points in virginia. There are cross cuts that are probably necessary to look at like a like economic security. The point is health care really dominated the domestic policy discussion this year. It was a result of a yearlong today. At least in the midst of that, you have a big debate from repeal to replace repeal and replace to singlepayer. The debate is moving in that direction. There is frustration on both sides of the Health Care Delivery system. I think there is an excessive amount of discourse and attention focused on exchangers. It represents a percent of the marketplace. Most people get health care through employerbased medicare and medicaid and 92 of the Media Coverage is on the exchanges and not individual marketplace. I think the big issue amongst are frustration with complexity and outofpocket costs, a huge driver of the debate today. If you look at everything that local as itused on, is natural national, and there are huge differences in dynamics that you have to deal with at every level. Into thefiltered discourse as well. I will stop with this and turn it over, what it means and where it is going. I would say the marketplace is not it not as bad a place as some would think. Irony of the withdrawal of the cost sharing reduction payments means more money is going into the system to subsidize higher level premiums and now people are able to buy gold and bronze plans for much less than they otherwise would have if they are subsidized. The population, over 400 percent of poverty who are exposed to high premiums and for benefits. That is unsustainable over a time and it has to be addressed. I would predict that markets today and insurers will have a good year in terms of their revenue intake. Mean it isot perfect. Health care is here for those of us to reform. We have jobs and with that, i will stop. Thank you. Thank you for having me. The title of the panel is the saga continues but rather than another star wars movie, it seems to me we have been through groundhogs day a little more than star wars. I think a couple of observations i would make right now. First observation is we obviously went through a tumultuous time where republicans were coming at this problem from a lot of Different Directions with the same outcome, which i think projects they will do the same thing again next year. We are likely to see a similar effort to hear on the repeal and replace of the aca it because of the policy imperative be and in part because of political imperative. If you look at Public Opinion polling, Republican Voters in particular, you will find a majority of them, and i literally mean a majority, still believe the top agenda item for congress to deal with is repeal and replace the aca. If you think about the echo Chamber Republican members of congress are getting when they go back to home districts, what they continue to hear is that the aca is a problem and something must be done about it. It suggests that even though they went through a lot of difficulty, policy difficulty in dealing with the aca in the last several months, they still feel a strong motivation and desire and need to do something about this. Debatein a tax reform right now. Up at somewraps point before we get too far into 2018 and then we get back to of discussions on the future of the aca. That is inevitable there there is a policy and that is that there are concerns about where things are going and a lot of that concern is in the marketplaces, which chris points out, it is not a huge number of people were talking about. I think you are seeing stories about declining choices. The quality or the nature of peoples plans are changing so you have higher deductibles and less access to physicians. Those are Problems Congress needs to deal with. They would ideally do so in a partisan matter but the bipartisan matter but the energy , that is not where it is right now. Our political system does not seem to be rewarding that now. Areecond observation is we in an interesting time with respect to develop to the. Iscussion on the left in my view, it is super interesting how quickly we have around a discussion government run singlepayer alternatives, whatever you want to call it. The reason different people call it Different Things is because Different Things happen to register Different Levels of popularity with the american public. Medicare for all does better than singlepayer. The reason you hear people talk about it as medicare for all is that seems to be the way to talk about it so you do not scare people into thinking we are turning into some european country. It is interesting how quickly the discussion on the left has migrated there. Because the next election is never far away, the reason why because when we get to 2020 ahead of the next president ial election, in order for someone to be successful as a democratic candidate, needs to have been fizz rlier and more more facet firstly and other people and that is part of why you are seeing the other dynamic you are seeing. We have not had a more earnest debate about singlepayer systems in the united states. I think we will see that debate. Whether it is substantive and thoughtful, i am skeptical but i prettye will see that significantly as we move through 2018 into 2019 and approaching the 2020 election. The last point i will make is i think republicans, where they have settled in terms of what they want to do with the aca, i think more and more republicans agree the way forward is emphasizing dams of federalism. The republican repeal and replace effort and proposals by senators graham and cassidy. Givingroposal focused on states greater freedom and flexibility in the form of a block grant and a lot of the aca structures. That effort was probably too far and too fast for a lot of people but it signals where republicans will be more comfortable. If there is anything the aca debate in the summer and the fall exposed is that republicans do not agree with a whole lot when it comes to health care policy. I think that is fine and healthy to have disagreement even within one side of the political spectrum, to think about the future of policy in a more thoughtful way. But i think it exposed fissures within the conservative movement on health care policy. 100 were to to pull in congress, the thing where you would get the most support is federalism, greater response for states. Is grahame foundation cassidy or the loosening of requirements around section 1332 that allowsrovision states greater flexibility to long as the systems comply with certain requirements and benchmarks daca establishes, whether it is broader we see the right migrating more toward the value of federalism and the importance of health care policy. That is how i see the environment. There is a question of, will when you mix health care and tax debates, bad things tend to happen. It is an interesting time. Thoughts to hear your on where we are heading. Made a promise to repeal and replace. I want to break it down now because there was a lot to the Affordable Care act. Parse it outed to a little bit. I want to focus a little bit on medicaid. What is the republican think behind that i think there are a couple of reasons why. The notion of putting medicaid on a fixed federal medication has been around for along time. Thats probably motivated by two things. One is a sincere sense that the federal obligation for medicaid isgrowing. Relatedly, theres a sense the program has gotten tobreak and that has to do with the expansion of medicaid through the aca be abroad and its good. Whether its a fiscalissue, those are the people policy motivations. The other side is an argument that if republicans want to undermine the aca the core of what the aca did is the Medicaid Expansion. Whether you think its a good idea or not we can agree that Medicaid Expansion explains some of the coverage increases in the aca. The other part is the politics. If you want to strike about theaca, getting at the Medicaid Expansion would be a big part. You can make the argument that youve done something because you have the aca. But there are some who like it and are comfortable with rolling it back. I think people realize that. Theres a sense that republicans wanted to roll it back. Thecoalition is more limited than we thought. But all the attempts included that rollback. And possibly beincreases slated because you get to the rollback that thefuture across all of the efforts. Im also hearing you say that it cannot be afforded. Is that true . Are those cost borne by somebody somewhere somehow, whether its clinics or Emergency Rooms across the country . Its fair to say nothing is free. So we need to look systemwide to figure out if theyre not absorbed by medicaid where theyobserved. Theres another issue just which is the most effectiveway to cover the population . In some states medicaid is very effective. In other states, less so. The variation across states something issued out and say i have an example. When youve seen one Medicaid Program, you seen one. Theres a lot ofvariation. Theres an argument to be made that medicaid isconsuming a greater percentage of the federal budget. Is that auseful expansion of federal spending . Wes would argue it is andsomeone argue it is in because theres more effective ways to get there. Is that doubletalk . [laughter] i feel sorry for lonnie. I mean if you like on double teaming. The medicaid debate exposes a couple of important points. There are republicans in the senate are liking it. But also the stakeholders in the providers. There thinking its not as bad as it thought it was going to be. Theres a funding stream now going to get payment for. Guess what, theres republican governors to expanded. So yes most people in washington who is the most effective opponent of the repeal and replace, its the republican governors. They had more of an impact than anybody else. Thesecond issue medicaid when you look at the Media Coverage of legitimate policy problems raised its largely been focused onthe exchanges. The Medicaid Program expansion, slashes thatwas expanded in a significant way with little negative reaction. Working quickly to repeal and replace that policy rather than focusing on the exchanges was a political mistake. Medicaid has become stronger than it has been other be no reference aboutthis. Republicans needed offsets to reduce some policy they wanted. I would argue, im pleased they strategically made heirsbut not to go just to repeal the expansion but to cap growth of the Medicaid Program. That brought in different people intothe argument. For these reasons, i think it was a huge mistake. The last thing, you often hear medicaid costs and growth isoutofcontrol. But on a per capita were growing at a very lowlevel. Its probably the cheapest way. The reason my democrats expanded is the cbo score is less than the cost because he couldnt secure the coverage at less of a class because of lower rates. Its going to be hard and i would argue against it. One other thing i think they made a mistake about strategically what happened right after the election which didnt exactly turn up where hoped or expected it was expected that we would have a quick repeal vote. It was a certainty. But what happenedwas suddenly the media focused on this debate and the way theyhadnt. I republicans who revealed this many times didnt feelthat debate because they didnt feel it was going to happen. I dont think republicans were prepared for that and they were produced for that product that the media was hungry for. Trump said i would never repeal something without replacing it. In that moment republican said ok we have to repeal and replace at the same time. Expose those are ready to produce a product that could sustain a consensus. Going forward in the aftermath at least i hope so. Theres issues of affordability and so on but underneath the more fundamental question of right versus privilege. Then it becomes more graphic. Where is the country in 2017 . Where thetwo parties with answering that question, is that a right orprivilege . I think what is happened, this is a change, and evolution. I may be a revolution. For the most part now republicans are saying we want to cover everyone but we want to do it our way. I went bigcriticism they have is it and cover everyone. Which is sweet, i likethat. But the political notion that we should be covering everyone whether writer or privilege, and no one should be exposed to discrimination. I think it has been folded into the ethos of the debate. That makes the alternatives of the Affordable Care act not single pair that are difficult to achieve. I disagree with that lately. It is not the case still amongst allrepublicans that is it an agreedupon bully. Lets all just agree that the goal of any reform that needs to move us towards universal coverage. I cant tell you how much blowback i gotfrom that. Not from your people, my people your people are verysupportive. It was not surprising. You can come over to our side side. What was surprising is that there are disagreements within the conservative movement about whether coverage is an meaningful metric or not. Its still very much, so i republicans are having a difficult time. If all republicans agree that we had abe moving towards that it would be different. We dont even have that, theres more disagreements the fundamental terms ofart. I think youre correct i think people in the Republican Party are saying coverage is not the best metric, sin honest way of addressing this issue. If you pretend otherwise, you can come up with the policy. What im suggesting is a political messaging is counter from the underlying opinion. That creates problems in terms of reconciling policy then rhetoric. I get confused hearing all of this. We had some of that here yesterday. What is wrong with the exchange . We heard congressman talking about the rising premiums in exchange. Members observed that there rising outside of the exchanges well. And whether or not they need to change the justification for opposing it. Whats your perspective . Why should it be curtailed or removed . I think there are some technical questions for example in some situations you have private marketplaces that are growing that have been stunted by some of the regular pieces put in by the aca. The problem the exchanges are experiencing are symptomatic of the Health Insurance system more broadly. I wouldnt say its in exchange specific problem. So theyre looking elsewhere. Regulatory uncertainty has been a problem on the exchanges, and if you look ahead to 2018, if you try to discern why premium are rising in 2018, i think most of observers would say that a good chunk of that has to do with uncertainty around the payment of the cost sharing. There will elements of the law when they were written that werent written in a way that were precise or werent written in a way that anticipated these problems. So the easy want would be, lets go back and fix those. Unfortunately that has gotten caught up in the larger political discussion around repeal and replace of the aca. I dont want do undersell but some states theres a significant problem with patient mix, insurer competition, rem proms premiums going up. Should this justify the repeal all of exchanges . Answer that in light of the recent open enrollment with the numbers are higher than in the past. It ends up being binary i think that it ended up being a binary discussion. In an ideal world, yes, you would just go and fix create the tech nick decreed you would pull the levers you need to pull for insurers to participate. No quarrel with that but thats not the reality of where we are, the reality is, exchanges are a part of the aca. If you dont like the aca, you cant like the exchanges. Thats just the politics, im just being honest. While i see a series of technical corrections could be made to improve this, you look at the proposal a bipartisan proposal on the table from senators alexander and murray, that would make some of these changes that both side would say those are reasonable things you need to do but it has go got close zero traction because of the environment were in. Chris. Just so many things in the exchange. First of all youre right to raise that premiums have gone up another context. Its not just the exchange. But also i think its appropriate to say that the nonindividual market is the hardest place to make the marketplaces work. You have a much more volatile population going in and us, people if youre an insurer pre aca and post aca always a problem and as a consequence always be some challenge that exist that dont exist in other areas. Secondly, notwithstanding that fact, if i was this is the ultimate irony of course, is that most republicans prior to the Affordable Care act would say we need exchange as an alternative to a big single pair, medicare, we need a privatebased coverage approach, and i would argue, respectfully butll be ignored by most, some people, wrongly so but is that you would work to strengthen the exchanges, specifically because its very hard to argue for such policies as, i want medicaid to be in the private plans, or medicare to be in private plans so premium senior without having a viable marketplace. So, i never really understood this whole discourse because i just felt, you know, what are you doing . Also, ironically, when the aca passed, we provided the states the opportunity and the resources to set up their own exchanges. Now, of course, mostly it was blue states who made that choice. In retrospect maybe they would be the one they would want to be thank you ones to do it. Why was the reason . They didnt want to buy into the Affordable Care act, obamacare, et cetera. The second was they were comfortable administering the Medicaid Program and did not want to deal with other populations over and above that and were going to leave it to the Insurance Commissioners to do what they wanted to do. So, you have to kind of understand the context. But i for the life of me i dont understand why we cant Work Together to fix this. These exchanges are actually functioning fairly well, short of the population i mentioned, the nonsubsidized population that has to be addressed and they can be addressed without blowing it up, and it should be. There is a way to the issue with the nonsubsidized population is precisely theyre not subsidized. That seems to be the big problem because the takeup is actually pretty good at the lower income brackets because of subsidies are relatively generous, and so in my mind, we ought to be focusing the discussion on those folks because we are buying out some of the base when you get up to 350, 400 of poverty. They get coverage through employers maybe, and what i would think would be a productive approach would be to say, look, lets focus on the cost sharing reduction problem, 250 of federal poverty and below that actually need assistance and are get usingable assistance of the exchanges. Thats the population we ought to focus on. I would say and i welcome that, for sure, but the truth is, Health Care Comes down to affordability and has to be affordable to a relatively decent packet. Dund have to be cadillac but needs to be a relatively decent package, and i argue the idea you have a cliff at 400 of poverty. Talk about people in california, its just like, boom, you dont have access to subsidies, theyre mad. And they have a reason to be. Theyre the cliff where theyre not getting any type of protection against the high premiums. Now, all one would have to do is be eliminate the cap, just eliminated, because its at, what, 9. 6 . Automatically is adjusted so you fix it. And you find some other ways to strengthen the marketplace, but i again, this is a very fixable marketplace, and it will always be a challenge, but we should be focusing on that and getting bipartisan interest in doing so i think we can build on the effortofalexander, murray and others. Is the goal to increase coverage and or the address the fact that individual dont get the benefit of the tax exclusion that employed individuals do . What problem are we addressing . There is another way to deal with that . Well, sure. I mean, look, im a democrat. I want to cover everyone. Figure out a way to make it work. We havent achieved the ultimate on give theres some off our party understandably who are frustrated. The Affordable Care act was pulling at not very great levels during the presidency. Not just because republican hated. Some on the left said you didnt go far enough. Now what has happened, its like, healthcare is like relationships. You never care more about them than when youre boost to lose them about to lose them. Whats that health care and is that what we have just seen in this debate, which is, my god, youre going to take i this away from me . You cant do that. Well, the point that the tax exclusion piece is in my mind critically important. If we werent operating within the bounds of political constraint, one could argue that why do we have a subsidy that is available to people who get offers of insurance through their employer but not available to individuals . And you could say the aca took a step in the right direction by imposing the cadillac tax, which is designed at some level to function like altering the existing tax treatment of healthcare for those who get it through their employers. At most economists would argue that the sort of original sin of our Healthcare System, there is was one, was this revenue rule neglect 1940s from the irs that made health care nontaxable to employee as a fringe benefit as way to circumvent wage controls. If you changed the treatment of health care to equalize or say were not instead of giving that tax benefit to through thank you employer to you, well just give it to you, that it might be an interesting thought experiment, but in the reality of where we are, its going to be very difficult to ever migrate to that kind of system. So, another thought i have, another question i have, is relating basically risk pool. Look at the various republican efforts here that failed, all of them dealt with the individual mandate, Central Health benefit inside way that would have fragmented the sort of single risk pool that i think was envisioned by the Affordable Care act. Right . So you have higher risk pools, lower risk pools and populations migrating. Is there a republican philosophy there . Do democrats believe to fervently in Community Rating that this is sacrosanct . We have watched with interest there because were in the risk business to a certain extent. Sure. So those risk pools are our risk pools and the extent theyre fragmented and all of a sudden you have sacred population here. Thats problematic. Is there a republican philosophy on that i milled . Well, no. So, look, the philosophical way to state it which ive never heard anyone to talk about, maybe politically has to do with transparency of risk, and so the philosophy behind dividing the marketplace is to help people understand exactly what it is their Insurance Premium is going toward. This criticism of the joint risk pool, which is effectively what the aca, created this Community Rating system, where everybody gets in, is that you have this tremendous crosssubs diedation and for a lot of republicans they feel like that is a relatively nontransparent kind of thing. Everyone is paying the same premium but in reality what youre doing is you have the healthy sick dying the risky. Now, any Insurance Scheme to a certain degree is that. Its going to function like that. If you were to create a separate pool for people who are of higher risk, then you could more directly see from a Government Spending perspective where is my subsidy dollar going. If you create a high risk or insurance rem system and say ahha, this amount of money is going directly to subsidize people who are higher risk, versus the Current System its a little more opaque. That would be the philosophical argument. Never heard anyone say that but thats what theyre getting at. Thats the policy behind it. And i actually think its a rational way of think can about the problem. The challenges high risk pools, reinsurance mechanism us, they have not worked particularly well in the past, arguably because they have not been funded fully enough or welldesigned enough. Believe those arrangements could work if designed and funded the right way. Again, youre dealing with the challenge of history and the challenge of how you talk about it. And, yet, independent of legislative efforts, states, like alaska and others, have developed reinsurance approaches and what theyve they found in that has stabilized the market place, reduced premiums, and now and then justified additional payments from the federal government because theyve saved money to the federal government nor the lower premiums. So, reinsurance is probably the biggest sometimes you get into language that are too associated with one party, and that is god forbid, right and n there was a reinsurance mechanism in the Affordable Care act which was phased out, which is the problem of the Affordable Care act. We cant replace something that was in the Affordable Care act because thats the Affordable Care act. We talk about stabilization funds, notre insurance polls. You should be talking about stabilization, not reinsurance pools weapon need to find some Common Ground on this area, and i think there is. I talked to republicans and democrats. Look, the whats the ma program . We have are insurance mechanism. Sunny because republicans want to make sure there would be mark place that works for the Prescription Drug benefit and the ma plans. The mark has largely worked, right . So, we got to slowly get through this where these theres not a win or a loss. Theres bipartisan movement, and i think really one important point look, ive been part of the partisan agreements and bipartisan ones and the best part about bipartisan ones is its much easier to sustain the policy and improve over time, and pathway partisan ones, it backs very rick, case in point very difficult, case in point, now. So democrats have to give a little bit to get the republican buy in, orbited the problem with republicans sometimes they think they need knock down a pillar in order to achieve the outcome, and that this challenge we face right now. So i think you said that we you think well be seeing another effort of repeal and replace in the first half of 2018. What do you guys think well see, if anything in terms of legislation affecting basically what were most interested in around here and is the Value Movement . Delivery model, form of payment. This is a crucially important thing that is happening in our Healthcare System but theres almost no popular attention paid to what is happening, and you have this huge reg that comes out on implementing mac contract, and iguarantee you there was zero coverage in the trade mainstream press, certainly not on tv. The short answer to your question is, at the legislative level, i dont see anything happening that would influence it. All the action is at agency, behind the scenes, and probably, frankly, better off that way. The more public attention paid, the harder it is to get anything real done. Well see a sustained effort talk about repeal and replacement. About large scale architectural issues but in terms of what in the room are dealing with daily, were be floored and shocked, even more floored and shocked than i was on elect night Election Night last year, if anything war to happen legislatively to impact the direction of where things are headed already. Are you aware of the discussion going on about a repeal of mips . Do you think how will congress react to that kind of recommendation . I think the bandwidth of these guys is so limited also it is, and think about how long it took to get rid of the sdr and how broadly agreed upon it was that was an important policy priority. And even that only got kind of got done because at some point people were sick of sticking around for the holidays. So theres no motivating factor here. The policy recommendation aside, i just dont see how theyre going to deal with aca repeal and replacement, tax reform, immigration, infrastructure, you know, funding the government, raising the debt ceiling. Chip. Holidays. So theres no motivating factor here. The policy recommendation aside, chip is the more important immediate probably issue. I just dont see it. Chris . Well, nervous. Tom price was here for a while and we were worried that wed see rollbacks basically to macra, more likely regulatory, and we havent seen that. Theres a level of anxiety still. I agree with lonnie that predominantly you they did get the cmmi reg out, the rfi out recently. People should engage in that. One area i find frustrating sometimes with the community of people who say, well, give us more signals or do something, is they, well extell us what the barriers are and the outcomes and consensus, and i think they Employer Community says they want to move to volume value. They should be a little more proactive about engaging on that. And pushing and providing cover for that. Thats the direction we want to do it. Would do it Via Executive action for now. Of course, the question about the role of cmmi Going Forward is a big issue, as to whether or not were going to do more than demos and move nationally, and whether that is a web site the Depth Department is going to move in that direction, certainly signaling they will be not and theres some in the congress who like that. Why . Because they want to get credit for policies they do and get scored by cbo and this is a complicated issue and i can talk to you about it later if anyone cares. But the point is, for now, focus on the executive branch. If they get done they have to get the reauthorization of the childrens Health Insurance program, the Community Health center program. S think medicare extenders and find off sunsets package of the extending the budget resolution, the debt limit, the tax bill. I mean, ice cream resolution week is tough by this congress. Lets what is our Congress Going to look like in 2018 after the election and. My view ir i hear people saying we had the eye lex here, this off, year election in new jersey and virginia and this is a signal for 2018. I mean, 2018 is a year the elections are a year away. Very difficult to say with any certainty today what is going to health one thing is clear, there is a lot more energy in the progressive base, i think, than there is on the republican side right now. In part because i think that republicans are dealing with these kind of existential questions about what it means to be a republican, and not to say i think theres a ton of Division Within the progressive movement, but nos just not being laid bare like then at the republican side. I public the odds slightly favor a Republican Senate and house but its close. Its going to be a very close election, and on the senate side, its particularly going to be disappointing if republicans are not able to do more to pick up seats because a lot of these states that are up are states that democrats have no business winning in, quite frankly. Look at the demographics and the level of support for President Trump in last years election. So well have to see what happens but its going to be a function of candidates strength, overall mood of the country which has to do with President Trump, has to do with the state of the economy, and then you get the sore of october surprises that come in and really shakeup races to make races come pet enough states like alabama where they shouldnt be competitive. Im sort of the under the category of making lemonade out of lemons the fact that President Trump won the Electoral College and is now in the white house, is probably a big help for those democrats who would have been probably more vulnerable in a clinton world. And in ohio and indiana and these other cities, missouri, et cetera, are looking much better. Theres a two of one ratio of democrats to republicans in the senate. They need pick up seats because in 2020 its reversed. And i wouldnt bet on it right now if i was the party, and i think theres going to be tremendous increase in democrats in the house. So, the reason why 2018 is something to watch very carefully politically in terms of repeal and replace, is do they feel its a political necessity to do something in this area because their base is so unhappy, and that is why all of us are worried about2018, because 2019 would at this moment look to be even harder to do repeal and replace. Interesting. So, i can see im getting the hook here but i think we may have time for a few questions and looking to see if we have the microphones around. Im seeing that theres people scurrying about. Theres the microphone and theres the microphone, theres the hand. Bob matthews has a hand up. While were waiting, the other good thing about the election we may say more states expanding medicaid in the next year or two. So watch that, particularly virginia and maine. You moon by the Initiative Process as we saw in maine no, by initially, by referendum and now theres a majority in maine, and then state of virginia, very sort of send there is centrist democrat, much more liked by republicans and perhaps even a house state legislature. Its very, very close. I feel pretty confident that well see significant progress. Bob matthews, i see you ill call on you. A question especially to lonnie. Im trying to understand the logic underneath i want to present maybe very briefly a hypothetical with two parts. The u. S. Healthcare is very expensive. The cost generate out of the providers because we spend the money, not the insurance. So, lets have two hypothetical markets. In one theres one Hospital System that is dominant, they bought awe the docks all the docks theyve trim their rates and go to conferences and decide, lets do as Many Services as possible, every freckle gets radiation, have heart is studied, everything, everything can happen. Make a lot of money, have profit. Another market, you have two groups who have been working on cost and quality for some time, and maybe because theres more Competition Among the providers, the rates are not crazy high. So, when people in the exchange go out and buy, theres going to pay lot more in class a, as are the employers, as are everybody else, because the rates are high and theyre doing too much unnecessary stuff. This goes on. Medicare and medicaid obviate the price difference because they gate price that they impose, not necessarily the utilization difference. So the problem i have with the republican side saying, what we need is more insurance competition in markets, is that the Insurance Company really, if you think about it, theyre like car dealership. If you dont put the cost and quality in at ford and gm, theres nothing much they can do except sign lights on it at the dealership. So we watch this going on and on. The only way to get the cost down is us, and we are forbid ton do it. By the economics of the world we live in. We came their do this, but the it keeps stopping us. The heat seems to me on the republican side and the democratic, is how expensive the exchanges are. Well, theyre expensive for in many instances because of the dynamic i just described. I can give you a list of ohio markets where what i just said is going on. The prices through the roof. May instances because of the dynamic i just described. The price is through the roof. ,hey dont get medicaid benefits are going to cost more than anybody can afford. And we dont get to that point. I think that assessment is right in part because we have this relatively ok health care system, right . The reason why the focus is on Insurance Premiums is because that is the actualization that most people understand and see in front of them. Not because its you are right, it is not particularly illustrative of what is really happening in terms of care delivery, the value of care delivery. All people are seeing is they are seeing a premium and the associated elements of the plan. That is probably why you see the discussion where it is, even though i tend to agree with you that Insurance Premiums are a reflection of many underlying trends and the underlying trends are, in many cases, not within the control of the insurance companies. They are within the control of other people in the system, but we are not having that discussion. I totally agree with you. I also dont know that we will ever have that discussion to be honest with you, because that is not what most people are seeing on a daytoday basis. Thats not where the political heat is being generated from. The heat is being generated from Insurance Premiums because thats what people see. I just say its a very good question. I think the consolidation issue is getting more and more attention now. Much more so than you might be pleased by republicans and democrats. I think the media tend to focus more on the insurance consolidation in the policy Community Cares much more and focuses more on the Health System consolidation. But it is becoming almost you can kind of feel this whole issue of market consolidation, politically getting a little bit more juice. It is still a little bit underneath the action phase, but im signaling to you a little bit more encouragement from ask the, i think both parties are interested. The Trump Administration certainly sending signals theyre focusing on that more and more. So in the end of the day, youre right. Historically and to date, this has been a huge issue, huge problem, and continues to be. Heres the problem and heres the challenges and i will throw it back on you all. The question is once a policymaker concludes its a problem, the question is, what is the policy intervention to address . And other than, like, enforcement of competition rules, etc. , like that, people dont have a lot. So if you all have ideas, i think of it a lot of policymakers both in and out of the executive and congressional levels, quite interested in talking to you. So heres a thought. Eliminate fee for service in medicare. Well, i mean another thought. Make Medicare Advantage bethe default. And seniors have to enroll into original. There are thoughts on the table out there that would drive to a better model. How would those be received in congress . Well, have you lived in a rural area lately . How are you going to get people to practice get access that ma plan in that part of the country . It is going to happen. Were always going to have some fee for service, and indeed i would argue a lot of ma plans would say way want to have fee for Service Model because our payment rates are based off that. So i hear that. But lets be real. The second issue, though, is look, do think the ma marketplace, we have a third of the population in medicare are ready. Tremendous growth notwithstanding the reduction in payments. Your trend line looks pretty good. Additional incentives, i think people will be interested, particularly on the republican side. Interesting, not seeing the pushback on the democratic side. But i think it would be a mistake not to combine some of the reform wes automatically get in ma, and superimpose some of the value purchasing techniques on to the fee for service program. I think it would be a mistake to not do that because we need to do better in fee for Service Areas in the country who have no alternative. Generally accepted in the Healthcare Community that 30 of this is waste. You hear that all the time and generally the case. How much is congress aware of that . I mean, think theyre i think they may be aware of it but i think the way they conceptualize waste in congress is different theyre think fraud and abuse and unfair billing. Yeah. I think that the challenge is that to get back to the point around these proposals, people like what they have. Even if certain degree, what they have is not particularly efficient, they still like it. And as we discovered from the front end of the aca debate shortly after passage, its difficult to put people into things that are not things that are comfortable with. And im not saying its not the right approach. Im just saying its the political reality. Think waste needs to be defined and executed a lot better. To me, we have to improve care. With safetyo issues. People are dying as a consequence. We have to i mean, i was just talking yesterday. To err is human. The issue the report was issued in the late projected 1990s. Probably wrongly, who knew, but 98,000 people are dying as a consequence of poorly coordinated care. Do you think that number has declined . Whatever the number is, has declined . Im a little bit dubious. We need to have a refresher on these issues and reengage people about the need to improve how we deliver care. I think you all can provide a leadership role in that regard. What is the symbol neither of you are bernie sanders, but were you bernie sanders, what approach would single payer advocates suggest with regard to 30 waste . Heres the thing. I think they conceptualize that 30 being totally focused on insurance companies. Administrative. Administrative costs and thats not the case. But, i think politically, their argument has traction with some people. Some people look at it and say, well, i dont understand why private insurers are involved in this. Everybody will make the argument about waste in the Healthcare System. But to chris point, we need get a better handle on what we mean bit, where is it happening, how do we sense that get at the goal of rooting it out versus something were dealing better that were dealing we waste, fraud, and abuse. Other questions. The final question or two the panel. Yes. We heard yesterday from our congressman, greg waldman, the democrats were wanting to reduce Medicare Advantage. Can you confirm why they want to do that . The democratic view as to Medicare Advantage. So walden said there are remain democrats sort of opposed to Medicare Advantage this, sort of historical and we were surprised by that. We thought that had largely vanished. I think that was more of a comment like dont look at me, look at them. But they are in power. Theyre the ones making the decisions. And the combination of republicans and a good number of democrats who now are very comfortable with ma plans, and have the long medicare byrid themile medicare with particularly disproportionate in urban settings, are not as as previously. Now, does that mean that if there are perceived overpayment or if there are real problems theycoding etc. , etc. , wouldnt say we should do more oversight, of course. Hope that people in this room would say the same thing. Amongst your problem, thats not your first didnt on your first list, let me put it to you that way. You need a microphone here. I dont see a clock going on here. Go ahead and ask you query. I will just repeat it. [inaudible] not to be rude, but i must ask them and your question is . It has to do with duplication and Affordable Care. [inaudible] [laughter] i think your reaction is probably, yes. At yes. [laughter] on that we all agree. We agree with you completely. It has to do with unnecessary services, etc. , etc. Unwarranted , variation, couldnt agree more. Other questions . Have we got a little more time . Theres a david joiner hand. We are actually just about out of time. If you want to do one final question, were just cutting our break a little bit short. Evan. A quick question. So from some of the other speakers throughout the course of the colloquium, at least for myself, i came away with a certain sense of discouragement about what to expect from the administrative side of the equation and the various agencies because of perhaps flight of people who traditionally have held the pieces together. So one of the things i think you mentioned this morning was how the real action is going to have to happen on that side of the street. And im wondering if you think that israel listed . Mylet me start with assessment which is i actually think there are a lot of very highquality people serving in important roles in this administration. I sincerely believe there are good people who are known policy commodities who are part of this administration. I think if the president goes in the direction people expect them to go in in terms of his nomination for the neck secretary of hhs i think alex is trim and asleep wellqualified and will be a very good leader for the agency. So im not i dont have the same measure of concern about the people in those roles. What i do have concern about a little bit is what the overall direction is going to be an white their marching orders will be. Im not sure theres been a ton of clarity on that front. To the degree that there may have been hostility toward the movement, toward value, i tend to think that was focus more in the form of the person who sat in the secretarys chair previously. That is ato say very important role. So if alex azar is the one were goingsignals, to continue to see Good Progress made. Are there others in the administration who are more skeptical about it . Perhaps. Then it becomes a question of who is setting the tone. But i dont doubt that there are very competent and good people filling the roles that need to be filled to get the work done. Good. I just say in my experience, in two separate administrations, not just the political but the career staff are high quality people. There has been some flight but not all. And a lot of the people remain. And the daytoday operation of the government, frankly, is the most underappreciated, underutilized by the Stakeholder Community access point to , change, that anyone we have this whole fascination with congress for the reasons that we understand. But the daytoday operations of the executive branch have far more impact on the work you do every day. And the Stakeholder Community, who by the way stakeholders in washington are people that we like and if we dont youre an opinion youre a special interest. So today your stakeholders. Should take heed with that message and not give up, because i think the will be positive negative things coming out of the administration. And let me underscore that is that. On that happy note, thank you, guys, very much. Give the panel a big round of applause. [applause] thank you very much. I believe we have a break of some number of minutes. Yes, ladies and gentlemen, please enjoy a 15 minute break. My