The 14th anniversary of the Affordable Care act is later this month. N Enterprise Institute hosted a discussion on how Health Care Law has survived and changed over time. And by republicans efforts to repeal and replace it have failed. This is about 90 minutes. [inaudibleversations] good morning, everyone, welcome to the american Enterprise Institute, and todays event, chasing the ghost of the Affordable Care■n act. Decided not to go with Abraham Lincoln vampire killer, but we work on that. First, i am tom miller, senior fellow at the american Enterprise Institute and periodically i always talke d you do with the Affordable Care act. I think the Obama Administration for necessary. I think the Trump Administration for making it more litigious and regulatory. And i think the biden tion for being more nostalgic and reflective. So thats where we are at the moment. But this is kind an annual newsy in terms of getting with the Affordable Care act. They comes up with the anniversary of the person you say is not another one of these anniversary events. I mean come on. We up to now . 14 or would ever since the ena in march 2010. Theres been a lot of changes since then and will talk about today but its not quite like another ghostbusters sequel. Are up to five of the net as a matter of fact. That one coming out later this year after life, after earlier i that one of ice. Now the son of the late original director is a one directing it. They had a female cast for number three. This one is perhaps going to be trying cryogenics. Not suspended animation. Thats just for the actors were appearing in it as opposed to the ghosts. We will try to do, bypass the pf the Affordable Care act and get into something i have to admit ive l a of false old slides have been used for while and am trying to reduce my Carbon Footprint so i tried recycle them. Whats attracted my attention to revising this topic is i need to ship it were quite a while. An excellent paper on the couple months ago by a younger professor there are you new communication can Gabe Scheffler and it was picking a fresher different look at the many iterations of the affordable ca what didnt. Thats reason for this title and forthcoming law review article, the ghost of the Affordable Care act. It also looking not only were we been so what am i say about what can happen in future. Theres a bit a force field around health care or policymang things that cant be done and get a nice job of explain■9 why we ght get in thew we can get Something Different if we change things around. Then we will have, gave his professor miami law school, of the background and at the white house, council of economic advisers, couplee and that cant so solicit from him as a first name speaker in the three different perspectives on that basic thesis. We will start with chip kahn whl get when anyone. Hes head o the federtems. We used to call them for profit but the work on the messaging of the call them taxpaying. We just do it for the folks out there really. Nothing else. Not only does chip at background in terms of the hostile sector and being a hospital of things in the witnesses past, in a previous lifetime he were a different hat for the health insurers, Health Insurance association of american have to havekx sliding reserve which is both harry and louise, i probably wouldnt use it. We can go back to 1980 when he was on capitol hill in one of his two tours of duty, also there for the nude revolution but this is one of working both sides of the catastrophic chapel talk about this site get someone experts about the legislative and the outside, their stakeholders duck, not special interest. But anyway to him or about how early goings and through time. Then our next speaker will beis. Brian is head of fairly new Health Policy think tank which has a lot of impact. Particularly among republicans and on the right butany ideas to offer. But again brian has wall street is before the Purchase Point person for Health Policy change is not reform, different opinions on that and in the trump white house. And prior history on capitol hill b side and on health side. Just a little bit after the enactment of the aca. Brian has been ae to use as a Supreme Court once being a Research Assistant at aei and the rest is history. In terms of what hes developed into since then. A bit of a content but hes been able to overcome it. Our final speaker, we have a range of perspectives can is John Mcdonough whos been on john was there in the sin which is important ingredient here, or get on senate health, education, and labor committeeith, under i. Inside national healt reform, about 12, 13 years ago. Good lessons of that. John also has other life. Hehe was once a practicing politicians we knew how to run for office and get elected and get those on occasion. None of us have to do wch i respect [inaudible] were all recovery in different ways but thats correct. So john will be our last speaker. I may have some additional thoughts i cant think of but i will come up with is affecting the public and will go to q a. That our basic format for or le. The speakers, and then the format. I have a lot of shot in time. I was either inchoate pandemics on the first rule of comedy, im asking a lot. Is you cant have a tight tent in order toet if youre going to Health Policy comedy, youve got to be able to have it organized lesson from there. Lets see what we got. Simple slide, et cetera but hopefully triggering some roundl ssanalysis. So first, why look backward to move[td ■u forward . Well, thats the best i can do. We got some things that this history that matters. Those who dont remember the past are condemned to repeat it. Okay we can start withne. Go to different direction. Try to karl marx. History repeats itself. Ve tragedy. And mark twain, differed little bit. He said history does not repeat itself butt final comment on ths probably donald trump that history does repeat, it just retweets. In any case welldo take a lookt what weve got to look at that. The fact is we dont know much about history in theu7■z same s, repeated and the witness movie, pl we dont know much of it history. We dont know much biology of whats in the science book but thats an education policy problem. A good bit of amnesia of happened or we remember it selectively come to have stories about what it is. There may be other lessons we didnt quite getnd and equipment and thus want to drive do looking back in this. Theres also some science and biology. In terms of National Health reform, wlicy reform reminds mes likely to be all while not until 2038, the cicadas come out, just kind of annoyed for a while and they go away. Sometimes our iteration of national Health Policy are more frequent the net, and sometimes they dont always get crushed underneath and Software Needs afterward. The supposed a convergence of twofe of cicadas, coming in of the parts, illinois and parts of the southeast but were going to miss that this time around. Coming to d. C. This time around. All these different breeds of Health Policy if you want to do this more as a promised you from the sides but would instead look at Health Policy and u. S. In terms of luck when he give you quantum physics. Ill just do newtoan laws of motion. The idea here is weve got centripetal fly apart and then centripetal motion in terms of it pulls it back in. Basic inherent stabilizing forces even things will be chaotic and then what really cements things together is what is a more powerful force in the universe than competent interest which isi inertia. Thats how we mostly hold things together. Periodically there may be somee looks like to be some wild swings but we never quite managed to completely go off the rail. Try a diffe image for the Affordable Care act. Might be a little extreme but ii can move in the direction. I decide not to use black night from the holy grail. Lets go back to the 1940s, the only dramatic movie Ronald Reagan is remembered for in kings row where he explained what happened was the local town physician cut off his legs to spite him because he was dating the wrong group of whatever. Theres this thing which i cant use with youtube rights when he wakes up in the bed home and he rest of the . Ok stucc hes missing both his legs. Some of the people who put out the aca might look around and say wheres the rest of the in terms of the provisions they thought were going to be in when they were fully of the middle le bit. I may be going a little strong on that part. I recom from 1942. The other thing i would have these, just remember what we hear a lot of lachaise. This is the lesson from bull durham, the interviews that you have to know your■d cliches eric weve got cliches of Health Reform and all the things it did. Did. There are nearly as many cliches in the acs acronyms and a lot of acronyms. Down to the stuff thats a little more lets see, running a little fast here. I probably have to have low bit of content in the midst of this. Thats wha i split second. The aca beyond age, at age 14. The reference to where is the cake . Those of you more inside sports fans, you might member in 2005 that having avi celebration, don at the capital city, they get two■]eady for the big celebration and he goes wheres of the cake . Kind of the same thing in terms of some of these aca anniversaries. Recent brief analytical overview before we move on to our speakers. Is a long time, memories are selective. We do then versus now. Not everything that was assumed those supposed to cee. But the magical thing is it doesnt matter if you damage or cut off a couple of those stools or legs on the three legged stool, as long as you have the magic of money and subsidies. When you have a rough crash landing on a few items and implementation, that money works as a wonderful flotation device. You just slip your seat cushion over and hold you up. There are a lot of tougher claims made about the aca in terms of everything it delivered. Certainly somed. We can its point amendment was but i believe that the audience here, o o discuss. But the main thing is keeping business in business and Internet Business did okay under the aca despite what were supposed to be. I make in some of the four seals the basic laws and motion but theres something when youre scoring this are urns out not to be the case. People were not predicting things like opioids, a covid pandemic, changes in eligibility rules for the various litigation and regulatory and his v changes whh ga a about. So what is the front instill into the same it all look like this in his what it will be. Turns out youre in a difficult because what you path isnt necessarily whated what stays around. Thats part of the larger message that theres the front in sale and that and afterwards okay what law article and have or as for scope would say, life is like af box of chocolates, yu never know what youre goingte o get into the open one up. In some cases the aca provisions work like that. In addition we have the fault of the war which made things donte was supposed to after the first shot about goes on. Ive gone long enough on this. Repeated at the end the lets go to opening speaker, gabe ghost hunting. That early hollowing but its a Good Opportunity to learn from the past and look ahead to the future. Gabe. , tom, thanks everyone for being here. Its really an honor for me to be part of this event, such an impressive set of panelists with such deep knowledge of the Health Care System and of the Affordable Care act pics am grateful for the paddles for agreeing tocipate and a burly looking forward to your remarks. I should see also its a particular honor to John Mcdonough here. Ive been reading his writing about the aca for many going to talk about today relies extensively on his wor my last count i cite your work around 40 times in my paper. Hopefully im not mischaracterizing anything too much. Im also grateful to tom miller and jack for organizing this■ event. I have to sayve though i was initially a . Little surpr me tot holding an event around my forthcoming article that goes to the Affordable Care act, myop w. It hadnt escaped my attention that at the time tom, the total number downloads from an article on on the social Science Research network was 13. I was an early adopter. Hly. I think six of those downloads were me. [laughing] you beat me onan papers. I have toms careful attention to even the most obscure corner of Health Policy internet, thanks for the invitation. This project camevidee from and then i will briefly outline so thiss project has been in the back of my mind for a few years now. I took a class of universe of miami and i typically spent a class or two doing an overview of the aca and how it changed the american Health Care System. And each time i have done this i have been struck by just how many important pieces of the law have been either repealed by congress, invalidate at leasterd in other ways since the law 14. So in the paper i call these the ghosts of the Affordable Care act. And s courts decision in medicn optional. As result of this decision around 2 million americans living across ten ten states includingre i live in florida still fall into the medicaid coverage gap and they also include legislation passed in 2017, zeroing out the tax penalty for the individual mandate effectively repealing it. As you may recall the mandate was once considered so central to the aca that it was believed the law couldnt survive without it. That hur wellfounded but Available Evidence still suggests that zeroing out the mandate penalty has resulted in a larger number of uninsured americans and hi there was also legislation passed in 2018 and 2019 repealing two important control provisions, the cadillac tax and independent payment advice report, or ipad come just to give you a sense of the kind of importance of these johnson gruber, the cadillac tax is one the most sfi provisions in the law, and peter or zag called ipab the most important institutional change in the aca. There■n was the cct which was supposed to establish a longterm Care Insurance program but deemed fiscally unsustainable in 2011 and was repealed by congress shortly thereafter. As result of that repeal, millions still lack access to any kind of longterm Care Insurance, or they are forced to spend down their savings in for medica. They also include the Supreme Courts decisions in hobby lobby and little assisters off the por which widen the exception to the acs contraceptive coverage mandate and undermined before the access to contraception. And i could go on. Now, its important having said all this to emphasize the ac was incredibly ambitious law packed with all kinds of different provisions, most of which still remain. Indeed, from one perspective the ac has proven to be remarkably resilient. So according to work by abby, mark, the ac is a most challenge statute in American History during its first decade of existe alone. The ac listed more than 2000 legal challenges and over 70 70 congressional attempts at repeal. And congress has subsequently strengthened some of the laws provisions in important ways, most notably by bolstering albeit temporally assumpsit on the aca exchanges. Has reshaped the Health Care System in important ways. While not critical into the acas and tax year, even the subject of extensive analysis and discussions in either literally hundreds of studies just on the effect of the Medicaid Expansion alone. But i think whats received far less attention and what i decide to write this article was that the acs that exist today is not the same as a law tha■l in 2010r taking these ghosts into account it becomes apparent that at least in several respects the law that exists today is more modest and its scope and the version that was origiy. Now of course its not uncommon for loss to be commended for change after their enacted. Longstanding laws like the solstice could act had been amended numerous times without seriously undermining the program. But by contrast its a the ghoss of the ac have an immense sum of central goals of the law, namely to provide Financial Security in the face of medical costs and kind of basic level of access to health care, and also to Reform Health the Health Care Delivery system soso it delivers less costly, Higher Quality care. In other words, is a major changes and they are at odds with another central goal of the law. These ghosts are somewhat surprising since they are in conventionalthe wisdom, social programs are nearly impossible to get rid of once they are inactive. And this conventional wisdom is supported by influential body of work in Political Science which offers a few reasons why and getting rid of social programs is so difficult. For one thing social programs tend to be popular and democratically elected representatives have strong incentives not to take unpopular actions if you want to stay in office. Also once they are established and implemented, such programs develop for our constituencies among the beneficiaries as those Interest Groups who mobilize to defend these programs when they are threatened. Comes to Health Insurance programs. In a recent survey of 11 different except for a brief two year moment in australia there is no case which universal Health Care Coverage once achieved has been undone. I think it makes it all the more more surprising that not only has several important pieces of aca fallen by the wayside the law itself close invalidated or revealed on multiple occasions. The chief Justice John Roberts reportedly not changed his min and on the floor as a whole mightt not survive. My goal was what happened the vulnerability stems in large part tradeoffs they were forced to make the and acting the approach. ■q it also had a Ripple Effect ended up the law or legally and political down the road. Road at draws on the Political Science literature that feedback effecr political environment. I tried to summarize the a. C. A. Enactment with this table. Just bear with pee for a a. C. A. D three articles which are listed on the lefthand side. Fiscal constraints, threat of opposition from key interest■rby trap that by incrementally expanding coveraj over time through jobbested coverage and medicare and medicaid the United States has undermined support for universal coverage since so Many Americans have coverage one form or another and wary of further Reform Efforts that would jeopardize the coverage they did have. And polarized political environment they relied democrats to pass the legislation. In response, legislative strategies in overcoming these obstacles. Fiscal concerns, president obama pledged that the law wldnt 90d pay for itself, avoid opposition groups and strategy referred to at the table or on the menu effectively of negotiating witho push through reforms over their objection and then care policy trap they settled on an incremental approach to patch the holes in the system than just completely overhauling it. It may have been necessary to enact the a. ,had what political scientists term self feedback effects, meaning they changed the political environment in a way that law postenactment and contributed to a. C. A. These effects are listed in the righthand column. In the interest of time, i will go through the first set listed in the second row frothe top. But in my paper, i am happy to talk about the other discussion. Take president obamas pledge that the law would pay for itself and expenditures wouldnt exceed billion over a 10year t have been necessary to win the support of physicianically conservative democrats but had other effects thatade t7it vulnerable. They led congress to slash subsidies for private insurance policies on the a. C. A. Changes and congress can only partially Fund Medicaid so states could challenge that and reduce the c. Immplet o. Score Congress Delayed the implementation of the main coverage provisions until nearly four years after the law was enacted. Reducing the generosity and delaying the implementation of the most popular parts of the law,■g they had effects of limiting support for the a. C. A. When opposition to the law was most intense. Some have spe Medicaid Expansion had been implemented and the courts been forced to confront the real consequences of arresting away Health Care Coverage, it would have been court to rerpd the medicaid provision optional, which it did. And for one thing the enactment strategies in the table a were geared to addressing more than one legislative obstacle. And its rather to illustrate how the legislative and to make it more volable post enactment. In the last part of my paper argue that these tradeoffs are not unique to the a. C think thee become more important over time. For one thing, the growing fiscal concerns over designing Health Policy. Interest groups have grown more powerful over time and have a strong interest in preserving the status quo. Congress has implemented government benefitslitical sciee submerged state which channels benefits the tax code in ways that make those benefits less salient to the public or otherwise support and at the same time, the rise of polar risessation and life to legal challenges. This point saying some important parts of the a. C. A. Are gone, it or at least much of it did. But other recent and important social programs have not been as fortunate. For instance, during the covid19 pandemic, the federal government enacted a sweeping expansion to social programs whh initially drew comparisons to the Great Society or to the new deal, but these expansions have for the most part proven short lived. The one prominent example is the expanded Child Tax Credit. In march of 2021 congress temporarily expanded the Child Tax Credit as part of the American Rescue plan and it was groundbreaking in support to nonworking families and was 7 million children out of poverty and to limit parts of the law, congress funded it for that tax year and supporters gambled that it was so politically popular that congress would bed to extend the law but this proved incorrect and congress let it expire at the end of the year. They did recently pass a law that would reextend but i dont know if if it will pass the senate and only last through 2025 and substantially scaled back from its pandemicyear level. In light of the a. C. A. Ghosts and near death■ experiences, te experience of these pandemicerh changes to the safety net and entrenchment tradeoffs, i suggest to you that conventional wisdom surrounding social legislation needs to be revised. Light of the weight ofs evidence i suggest social legislation like the a. C. A. , the expanded tax credit is more vulnerable than the conventional wisdom would suggest at least during its early years. My projs descriptive, trying to understand why the out to be so vulnerable and documenting the effects of all these changes im p putting it out from the perspective that someone supports a rebus safety net and using this legislation as a p conclude my o explore some ways that lawmakers might address this in the future and make legislation more durable. The one option is to do playing the game better. Mainly the political scientists working in this area have tended to argue that lawmakers should look at the feedback effect the way laws shape their environment. Their argument is that lawmakers should be prioritizing not just enacting their bill into law but designing it so it will be politically popular and it will become entrenched and phasingy e so it will be salient and traceable to government. This isnt revolutionary advice. Savvy politicians like f. D. R. Have been aware that the design of programs can affect and with some exceptions have not been followed in the case of the a. C. A. However i am deeply skeptical of this approach since my project suggests that the strategies to enact the a. C. A. Or other social legislation are dectly at odds d towards entrenching these laws. To overcome budgetary constraints legislators the gene laws benefits or implementation those benefits further out to the future but that diminishes the effect of the law. Alternatively lawmakers can the benefits. And extended. Instead of trying to play the game better, lawmakers need to change the rules of the game by targeting the lan institutions that give rise. So iy preliminary pee prescriptive suggestions for how lawmakers might do this. My first suggestion is to target the specific obstacles legislat. They could ease the budgetary like the paygo process for lawmakers to prioritize their budgetary effects. Mill secon■gstion is counterintuitive, number of veto gates and eliminating the senate filibuster. I said it is counterintuitive and scholars have suggested that although the filibusterakes it harder, it makes them harder to be repealed. But i suggest that because veto gate gives disproportionate power to a few members of congress they render more potent and make it more necessary to resort to legislative strategies that have selfundermining effects. If you think about a world where where president obama and the democrats needed 50 votes in the senate to enact the a. C. A. In, is that the version of the a. C. A. Tay would have been enacted would have been more generous and would have been implemented more quickly and more politically popular earlier on than the version we ended up with. I have no formal proof of this, the pro entrenchment effect would outweigh the needing 50 votes to repeal the legislation and make social legislation more durable. These recommendations getting rid of the filibuster have been extensively dated elsewhere and have pros and const i dont go into but entrenching social f that conversation. Ill stop there. Thanks again. And i look forward to everyone elses remarks. Thank you, gabe. Chip. I feel forest gumplike. I have been around for a long time and not try to match toms witt. Gabe gave us a great overview, although in terms of his last remark and getting to 51 votes, i think he should think what obama if he had to deal with senator manchin and senator sinema. Whether 50 or 60, ill get to that in a moment. But the process is the process. E things that reflect from3 somef the comments gabe made. First, i am going to go back into history and i have my own quote which is from what is past is pro logue. In terms of obama success and thre they were two historical events that set the precedent for both, which are important to keep in mind. That is the first area im goins everything but at the end of the day, it doesnt matter, only one thing matters, two things, one to pass legislation and the other is the votes. If you have the will and the votes you can figure your way through any process and we see that every day, if you dont have the will, you are not going to get the legislation passed. And i got an example that i want to talk about there which is a. C. A. And why it cam and then finally describing the ghosts, i think in terms of the best laid plans that you were ot myself and men often go awry. And despite the expertise, knowledge and experience that goes into the legislative process and i will take issue with gabe a bit, the issue of laughability is1j important for those designing legislation. At the end of the day. There are things that you couldnt predict and just because you think you do it right, like find out until you start living there some of the things that happumen■cl you nevr would have expected. First, in terms of past is pro log it is clear to me the success of. A. Really was made by the obamations strategh was built on the failure in 1993 and 1994 of clintoncare and one of the four themes that comes ro that white house. One and this one i think is surprising in washington, the white house basically took no pride of authorship. They set out premises and the president wanted to get universal coverage, but he left the details to the hill and he negotiated and he6n played in te game but in the end of the day it was the hills product. Second he sought partners, not adversaries. An adversary not wanting to be in 1993 and 1994, i can say thats no fun but it can upend the legislation and whether there are interests or stakeholders or whatever, they count, they represent the public in many ways and making them partners and bringing them on board made a. C. A. Possible. Third. And this fits with the model that gabe descred, ther that thk for a. C. A. Had to be built on the Current System. Whether it was built on how the Current System operates or not may or may not be a reality and brian will point out a lot o problems with the exchanges that reflect that construct that was different than the previous individual market, but on the other hand, at least they gave the illusion in the design that they were building on what works in the Current System. We can debate it worked then or worked over time, but that was the notn. And then finally there was a lot of kabookie theater in the senate during the early consideration of the the end, tn knew it was going to be partisan and only was a democratic bill. They would have loved to have bipartisanship. But i think the crashing o clintoncare in the senate at the end of the day showed that thato happen. I dont think they had a choice. Thats the obama model and why i think they were successful. Why do republicans think that a major piece of social legislation could be repealed . We could be we peel in place, but repealed. I have a lot of experience with that because back one of the people that developed the catastrophic law since its enactment. And then i had the experience im not going to call it the pleasure on working the repeal bus i for members of congress that both framed the legislation and then rep and ironically iscernible] the first day the repeal was being considered on the floor i was■atructed by the Ranking Member on ways and means give him a draft. And bill archer, the full Committee Ranking who at that point was the author of repeal with congressman done ellie asked me to write him a draft. I wrote one draft one day and the other next. But the bill was repealed and its argue there were three key members of the congress who made the repeal happen, congressman archer and congressman done ellie and mccain because senator mccain was the lead on repeal in the senate. It was this and then repeal was considered in the senate, he voted against repeal in place. A notion that a may scrr piece of legislation that had an im major population could be repealed was already set in precedent. Now, we can argue about whether or not medicarebe set out some guidelines because implementation was problematic in terms of gaining public support for it, but putting that aside that set a precedent that surprising to men terms of its lasting power of the g. O. P. Repeal and replace that actually to this day set up former President Trump said he wanted to get back to repealing a. C. A. And second point that on the one hand processes everything, but its the wheel and the boats make the difference regardless of the process which is most interesting to me that is unfortunate the unfortunate death of senator kennedy was the key matter that allowed the bill to pass. And why do i say that . Because at that point in timeman or senator sinema in congress tt that Pivotal Point back in the day it was senator ben nelson. And i can see no way conference report that would have satisfied the bulk of cauce and the senate could have done in nelsons vote. When the senator unfortunately died, there were on democrats and the senate looked at the house and said to the want this bill to pass you have to pass the senate bill. There was a reconciliation later but at the end of the day i dont want to say that was covered t much you can do in reconciliation to actually authorize all of the law t a. C. A. , it had to be in regular order and thus it passed because the house was forced to pass the senate bill i should say the senate bill with all its flaws. So finally, let me look at some of the things that went awry. There was some discussion about the Medicaid Expansion and in a sense the fall tion is to me fo much irony. The irony is that everyone thought that the individual mandate was the ultimate pivotal and the Supreme Court stood by it and at the end of the day itn states that fell by the way side. I dont think the individual mandate arguably was that much of a material loss because if you remember krrmt b. O. Predicted 92 to 94 insured rate and we are at 92. 3 . So we are not too far from that. The 92. 3 is a little disappointing because we made a deal based on 94 spitals would f our payments if we could get that 94 . Who could have thought that the Supreme Court would have come become. Going back to the design issues, was it faulty design . You could say t hand, but i think those people who are very expert in right thing when they wrote the law. One of the most interesting things and ill conclude on this to me about a. C. A. ■m about coverage for the new programs, its actually about coverage for the old program, which is medicare. And a. C. A. Took cuts from hospitals and cuts from health 6 billion in cuts through 2019 from health plans. And c. B. O. , Congressional Budget Office estimated that there be reduction of 4. 8 million people1 million t cuts. And what happened . And this goes back to plans awry. Because i think that those who framed the bill on the democratic sid enthusiastic about managed care and not enthusiastic about Medicare Advantage. Thats why we got Accountable Care organizations and other sorts of visions of how we would control costs and deliver organized care over but what happened . What happened was in 2019 and gt 2024, we had 22. 2 million enrolled in Medicare Advantage. And instead of a p 6 67 member in rebates 2019 it was 107. What happened . The bill had a nice Quality Program in there so if you got more s get more money. It was around■ 15ilon and the Insurance Companies figured gee, if i can consolidate with a 10,000 member plan that has all those stars and i might have 300,000 members then i all thoss and thats before we get to risk adjustment. Smart insurance guys created a situation where they could get a lot more actually provide a lot more upfront not going to argue or valuem judgment it and then hired joe namath to sell it and more people in medicare Medicare Advantage and with respect to the cmmi and the valuebased pud a. C. O. s, at the end of the day if most Medicare Beneficiaries are going to be in some kind of valuebased coverage, its not going to on service that is narrowing as a portion of medicare. With that, i hope i offered some pearls that will be worth of discussion later and appreciate the outline that gabe gave us to this discuss thank you, chip. Brian has spent a good deal of his career sometimes to draws. Go brian. Thanks for allowing me to participate. Gabe, thanks for the painful and thoughtful trip down mor a. C. A. Y the law that the health care indury written. The main components, the large new subsidies through the exchanges through Medicaid Expansion, through 340b are all growing. Health insurers reaped windfalls and enjoying their position. The main component that the industry disliked, cadillac tax, gone. Health insurance tax a, gone. Medical device tax, gone. The independent payment advisory board, gone. All in big partisan votes. The conversations in the board rooms of the Health Industry were to support enactment to get all the stuff they wanted and didnt like and thats how it played out in a way that substantially increased federal deficits. In retrospect president obama guarantee wouldnt increase deficits had been made to get the law gabe discussed te Class Program significantly contributed to the laws purported deficit reduction. Thats because collections needed to come in foryears before any payments were made. One year after the secretary sebelius said the program had serious underlying programs and the administration would not implement. One year later, it was student n redesign which was used as a. C. A. Payfor is working out in favor of the government. The core Central Planning aspect of the a. C. A. Has failed. I dont■f believe gabes paper, the centers for medicare and medicaid is increasing deficits that failed to develop models that improve health care and lower costs. And harming policy coverage. The first seven years of implementation of the a. C. A. Occurred iting administration and took many legal actions to ease political opposition to the law. Most famously, president obama admitted in the fall of 2013 thata4■ his promise that people could like they could keep plans if t■ny like was in the true and they created a new set of grandmother plans tay could avoid increasing costs. If thepn Trump Administration de this, it would have been called sabotage. It provides significant relief from the employer mandate penalties and took action to offset the Medicare Advantage payment rediscs prior to the thl demonstration program. The effoo repeal and replace. It restricted plans and compelled people to buy coverage and new■ taxes from spending and enormous of washington Central Planning and it was unpopular. Intense opposition to the law should have been expected. That negative public reaction contributed to landslide election and ended any hope of acome did iting legislative policy for the a. C. A. Four republicans, the best chance to change policy direction would have been to capture the white house in 2012 since its core ihad not taken hold. One of the ironies in recent political nominated the man least able to make the case against the a. C. A. Massachusetts governor romney embraced the elements of the a. C. A. President obama was reelected and the implementation of the a. C. A. Continued. But it went poorly from 2013 to 2017, planned deductibles soared and v majority of coops failed. In 2016 repealing and replacing oaker obamacare was part of the platform and republicans gt the car. In 2017 we had the most significant efforto modify the a. C. A. Notice i did not use the phrase repeal it became clear in early 2017 that the leadership of the party was not supportive of significantly repealing the a. C. A. I think gabes paper makes a typical fault to say the a. C. A. Might not have survived for john mccains thumbs down. Most of the a. C. A. Insurance rules kept the subsidy in design form and permitted states to maintain their expansion just as traditional rate for medicaid not the enhanced rate and that legislation went too far for the senate. The socalled skinny bill only had three elements, elimination of the individual mandate penalty, the delay of the employer mandate penalty and usa 1332 waiver. If that bill passed the senate, the product would likely have been closer to what the Skinny Senate bill policy would be similar to what we currently have. Legislative effort failed for a lot of reasons. The one reason in particularly important, the Congressional Budget Office. Ed a mythical power to the individual mandate. If you remember, president obama had campaigned against the individual mandate, but his position changed because of c. B. O. According to c. B. O. The individual mandate would compels it made the coverage and cost■jc better. These assumptions continued through 2017. Republicans reviled the individual mandate. Every proposal they would inod eliminate it. Dough spite republican bills maintaining most of the Health Insurance, the individual mandates led c. B. O. To project e coverage. And although this number was bogus, as be congress eliminated the penalty, the number was the top data point cited by democrats and media for have the republicans bills were harmful and it was devastating for the efforts. With respect to this paper, one of the main a. C. A. Designs that led to its entrenchment was the makeup of the Medicaid Expansion. With almost all expansion spending financed by washington, states had significant incentives to expand medicaid. By 2017,■a Many Republican governors expanded the program, and those that did did not want to roll back the federal money. It created a significant divide within the party. In my view dividing republicans in states on the Medicaid Expansion was has probably contributohe a. C. A. s entrenchment more than any other element. There have been wins outside oe ones favored by industry. The tax cuts and jobs act eliminated the individual mandate penalty, the outsized and unrealistic effect of the mandate ant repealing it, led to outsized and unrealistic budget savings from fewer people ge■lttin subsidies, making it a useful pay for. Second, the refusal of some states to implement Medicaid Expansion. I dont have time to get into the numerous problems with expansion, but i encourage you m paragon on the subject if you are interested. Third, the regulatory the Trump Administration to expand options for employers and families such as through shortterm limited Duration Insurance and individual Coverage Health reimbursement arraemlly, chip mentioned this, Medicare Advantage has emerged in a much stronger position tha. C. B. O. Thought m. A. Growth would flatline. The office of the actuary at c. M. S. Thought the a. C. A. Would lead enrollment in m. A. To shrink by half. Yet m. A. Has continued to exhibit strong growth. I think there are a few other assertions in the paper that are incorrect. Im going to mention two. First, there was not Trump Administration sabotage. The main administrative action taken by administration was to comply with the federal tkort ruling court the government couldnt make caution kwrar reduction payments to Insurance Companies absent a congressional appropriation. This resulted in regulators allowing the practice of silver loading. Which vastly increased a. C. A. Subsidies to insurers. Thbidenistration could have asked congress to fund the c. S. R. Program. Its chosen not to. One other trump major a. C. A. Supporting policy, those individual coverage■ are incret using employer dollars. T. Second, there is mixed evidence of the a. C. A. He effect on health outcomes. Life expectancy in the u. S. Decreased from 2014 to 201 the first three years that the a. C. A. s provisions took effect with greater declines states m. In closing, let me offer perspective on policy moving forward. First, policymakers should rationalize federal medicaid subsidies. It makes zero sense for the federal government to pay a much state expenses for the nondisabled workingage population than for traditional medicaid populations. There is no sensible policy that would have resulted in that outcome, federal discrimination against lower income children and people with disabilities through this dispad end. Second, as a recent paeuper from paragon discuss, the a. C. A. Exchanges was not an efficient coverage expansion. Its cost a lot more to decrea the number of uninsured than expected. Much of the subsidies have gone to people who already had coverage and people who pay nothing for their coverage. The subsidy structure gives insurers enormous Pricing Power to increase prices with the full increase borne by policymakers should not just continue to enhance subsidies and rather focus on a better targeted and more efficient structure. Thanks again, tom, for asking me to participate. I look forward to the discussion. Thank you, brian. Well squeeze our discussion because im contractual to go t. John, you have enough time. I wanted to ensure that. Last but not least, because he was flying in from boston this morning. Thank you, tom, for pulling this together. Thanks for gabe for incisive and really interesting its always valuable to get some perspective forgot about and overlooked. I have some comments, differences in interpretation, probably with everybody. I do ha■ve aim going to see ifl it up. Here we go. Heres my firstke chip, when i r i thought back to 1988. Have we ever, in fact, repealed a major social welfare benefit law yes, we have. 1989, 17 months after the law was signed by president Ronald Reagan. I know you cant take your eyes off that picture, and neither could i. Thats from left to right, thats john dingellhenry waxman, otis bowen, standing near the front, da benson, max baucus, pete stark surrounding Ronald Reagan. Forgive me the Power Pointer cutoff, john chafee and bill were in the picture as well. Look at max by the way. Does he look like■ a Young John Kennedy or what . Whats interesting to me, what stands out for me most about the that it was a law that was the biggest expansion of medicare iy republican white house, republican senate, democratic house. It was fully paid for. It was fully selffinanced. No addition to the deficit or anything like that. And the Financing Mechanism put what was either ancrease or a supplemental premium or whatever label you want to put on it on mostly the upper income seniors. That was the problem, wasnt it . Who already felt that they ce on their own dime or through their employer. And they revolted. In many ways, particularly in chicago, against dan rostenkowski. A lesson there. A lesson to be learned of what happens when you have to pay for stuff and how difficult it can get. Ditto in 1997 th balanced budget act, democratic president , Republican House and Senate Passed a major bill to balance the federal deficit. Mostly by cuts to medicare on■ i hospitals, on physicians creating the low Sustainable Growth rate. There is a lesson in this it seems to me that republicans incorporated from this which is that its tough to pay for this stuff. Maybe if we need to think more carefully about that. Its a lesson i think that 21st century and what we can see. I took gabes provisions, the 10 provisions and i just tried to look at them in different ways. This was the way that i found most interesting. I put them in order of the date of 10. Bottom two, Workforce Commission has never been repealed. It was never funded. The coop program ran out of money that congress pulled back. But the other ones you can see, you can look at the states. You can see how it repealed. Two of the major ones by the Supreme Court. And then the rest through statutes, most during the trump era, as well. If you look at those. T. And then my last column, we can probably disagree about, were these central in some way, fundamental to the a. C. A. . And except for the state medicaid mandate and the individual mandate, i would say the rest of them, they are all important, they are all substantive, they all matter. And aere really central to the success or failure of the a. C. A. It turns out the individual mandate that we thought it was very central, and i did, too, turned out to less essential than we thought. Interesting, you look at details and numbers five, six, seven, eight, they were all pay fors. They were put in there. They are substantive policy, but they were not put in because, geez, we have to dcause we had s to, a, finance the law so it th. Democrats made a commitment right at the start, this is going to be scored by c. B. O. As deficit neutral, and that was a Mission Accomplished. Whatever concerns you want to put. They did it. They met that requirement. Or it had some other significant impact. Interesting dynamic. Most of the changes happened, of course, during the Trump Administration. But there is one point that i really have to take issue with. Gabe suggested in his paper that, so a lot of these changes ended up undermining support for the law. I look at the dates of when things happened, and then look athi keyser Family Foundation kaiser Family Foundation monthly favorability, unfavorability for the a. V. A. There is a clear trend thats not hard to saoefplt i dont know what happened in january, 2017, but it was a turning point for popularity of the a. C. A. Of course w making his clarion call for repeal and replace. And since donald trump became president , a. C. A. Flipped to bee favorable than unfavorable. If the big change, of all the changes that happened, undermined support for the law, this chart doesnt make sense. And in fact, the law has become significantly more favorable. Over the past seven years, six to seven years now. Because its a core 101 principle of behavioral economics. People fear hypothetical losses. More than they aproerbite hypothetical gains. So when donald trump came in and said we are going ttake from yot two weeks and well tell you whats coming and its going to be hike. It was a massive urecedented resistance from the American Public that really defeated it and led to john mccains thumb down. I agree with brian, the skinny bill that came before the senate was nothing. The process going. G to kee it would have still ended up in a car crash im sure. Then you look into this decade and the Biden Administration where the a. C. A. Played a Critical Role for the first time in American History since we have been counting thethrough a sharp economic down turn, and we saw no spike uninsured. The uninsured rate stayed the same. It marginally went down. Then the Biden Administration put in the extra subsidies for arpa and through the. A. , can you see the popularity in the law. I think the notion that there was a decline in popularity became hard. I dont think that holds water. I did a piece a few years ago for the journal of Health Policy politics, and law on the 10th anniversary of the law, where i wanted to look at some of the provisions that people dont write a. Just this is the tii used at the top. I have the reference at the bottom. I picked success, failures, and mixed results. My count is there are 487 sections in the affordablcare signed into law and amended by the followup law. In that, when you have 487 sections, you have winners, you have somewhere its a matter of disagreement or so worth so forth. I think the important thing to keep in mind is that whpb the a. Did within the a. C. A. Structure, there are the major league provisions and there are the minor league provisions. Thee title 1, we thought the individual mandate less so. But the advance payment tax credits, the subsidies, the insurance exchanges, the marketplaces, and most of all fundamentally guaranteed issue, all of the that came together, you go with those. Thats what people were going after in some of the supreme cocases. And you would have done fatal injury. The Medicaid Expansion in title 2, you get rid of that, you have blown a major hole in the a. C. A. And then title 3, the■n snluet was envisioned withare. It has the the results have been far less to write home about than people thought in the first decade. But that was central. That has never really been challenged at either party. What i would note is just one thing to keep in4 mind, if i can go back here, the pay fors. Interesting. There have been by my mind there have been two major Republican Health laws in. the medicare modernization act in 2003. Created the mips program in 2015. Both of them overwhelmingly deficit financed. Not paid for. You look h the pay fors, the four pay fors in a row, all done byd congresses. And they did which had significant revenue impacts for the federal government, because the benefits keep going and these were payt any point to try and pay for any of these by the people pushing this repeal, answer, no. I cant tell you the number of articles i read since i got into this game in 1985 on how awful the for employer sponsored Health Insurance is. Bipartisan. Particularly, when the cadillac tax was repealed but it was put in the law because max baucus was ordered by harry reid that he could not he could not mass width the employer Health Insurance tax exclusion. Couldnt do it. It would be a failure. We would lose so cut it out. Baucus had to go back in. It was john kerry who came up cadillac tax. Ed ok. Absolutely flawed. You look at it. And you look at the design and so forth. You can say thats just what made them think that that could do it . What were they smoking that day . The important piece is that when it came time to repeal it in 2019, which ever ye, or 2019, was there any consideration or effort to say, ok, we cant keep the cadillac tax, but what an opportunity to go back and try to come up with Something Else to try to it . Never to my awareness a conversation about doing that. Lets just so i guess part of my consideration is that payingl law in the United States, in this century, e 21st century, thats so 20th century. That just doesnt happen anymore. Im wondering what happened to the efforts onhe part of republicans like durenberger, like■mhaeufrby khaeufrbee, when you chaffee, when you try to make changes, you have a deficit, it has to be paid for. I havent seen an Initiative Fr r now, 24th year, to pay forhe changes they want to see. I put that out there as an observation. Ill close on this. People have been saying, oh, a. C. A. , it didnt meet its targets. No coverage. Waste of time. Big waste. You cant say that anymore looking at where we are on the exchange coverage. We have the rate of uninsurance in the United States to the lowest it has been since we started counting. Not Mission Accomplished at the level that chip thought we would get, but when we wrote the we we Medicaid Expansion be a state option among other things. But substantial historic progress. Then the other thing we get is people say, ok, yeah, you you d. No changes at all in costs. Youll get the look at the date. Look at the date when it really startsod 2010. When it levels off. That was ther that the big major cuts that chip had to pay in title 3 of the law took effect. And went on. Ancoue not the only piece, but o dime, this is 4 trillion in medicare spending that people thought was going to happen that did not happen. Just to note that on both sides, on this 14th anniversary o and s definitely not a home run. We are definitel have major cha. As we look back i think that we also its hard to say that on both coverage and on saving money, that we didnt make significant serious Important National changes. And i think thats the piece to keep in mind. Im sorry, not the long laundry list of little provision that is got saved or didnt get saved. Thank you. Thank you, john. I was about to have to file for cloture. We appreciate it. It would have been a lot of rebuttal on the panel, we need to go to our audience with the time remaining. Lets wait for microphone to come to you. Introduce yourself. Short of the oped. Question. Start in the back. Go ahead. Thank informative. Paul with nefron research. Id like the panels opinion on what the prospects are for the enhanced a. C. A. Tax creditsgy depending on the outcome of the election . Especially if we have a republican washington nextuz quickly. One minute apiece at most. Go ahead. I think it does depend on the election and what happens. If you have a democratic trifecta, the lt will get extended. Probably not for 10 years because it costs so much. If you have ■8a republican trifecta, it will probably disappear. And if you have a divided government, it will be a jump ball depending on the configuration and the stage is set deal between, on the one hand, continuing the subsidies, and conti cuts from t law. If there is a deal, i think this is possible candidate as a major component of the deal. Bri part that have is a good point. There is a lot thats expiring at the end of 2025. The trump tax cuts on the individual side are expiring. They have set up other cliffs that are expiring. My hope is that the subdy, which i think subsidies, which were inefficient, if republicans are in power, they would nxt they wt do it for enrollees who already have them and not allow new people into the enhanced subsidy structure. Move along. Carl. Carl, worked on Health Policy for a long time. With both john. I think they both made really good points. Ian, the fact that h industry basically wrote the bill, made a lot of money off it, and we have too High Health Care costs. John, i think youre right. Most of what the a. C. A. Promised, it did. It covered about as many of the uninsured. We still have o cover. We need to cut costs. We need money for social security. We need money to reduce the deficit. We need money to help people raise kids. Stuff like that. The question being what would you guys do with this Health Care Industry out there thats so powerful, eithe enhance government bargaining or private sector bargaining to get our costs down morin other countries . On the supply side of the market we should look at undoing Government Policies that increase prices. Medicare pays more for services delivered■ in hospitals that could be provided in physician offices. We should pursue cite neutral payments in medicare site neutral payments in medicare. On the subsidy side, paragon has a proposal that would direct more of the subsidiway fr th industry and away from direct payments from the treasury to Health Insurance companies to the individuals. And let the individuals have greater control over the subsidies and over the spending so that they are making decision that is are maximizing their value and they have incentives to i think its important to point out that t s number that john shows us in terms of where medicare spending is is reflected in overall spending. Im not arguing we dont spend a lot on health care. But the amount thats spent has plateaued and the key thing here is gettingovered. The a. C. A. Was with respect to brian and what you said, was not about the providers. It was about assuring that wea l americans in this country. Because jobnee they had Health Insurance coverage. It was not completely successful, but tpraeubgly frankly, considering what else could have happened, it was extremely successful. Coverage today. If you go to california or go to new york or some othertes where they have completely implemented a. C. A. , except for the undocumented and a few others, everybody has Health Care Coverage. Wendall. Your mic is behind you. Thanks for this discussion. I enjoyed it very much. Ill make a couple comments. The folks at home love to know who you are. Wendall, now at brookings, i was a long time staffer to speaker pelosi. The medicare catastrophic, i point out at this point i get the blame for the credit for that because i convinced rostenkowski that the elderly shouldare program. But now we do have an income related premium in medicare. 9 of the elderly pay for t. They got the tax anyway. And they didnt get the catastrophic coverage. And i do think we have some big discrepancies discrepancies between the a. C. A. And medicare ahe premium side and catastrophic. The only thing i would say is i think a lot of the implementation dates in the a. C. A. Were not politically determined. They were jused on how fast we thought the provision could be enacted. Administratively implemented. I make those comments. Thank you very much. One other thing, brian, i do nos still paid for, even though we. Its all on the credit card. Its paid for. One more in back. Well have to jump. We are about to hit a hard cap. Hi. I have a very about the perceived value of a. C. A. Plansb when you look at the introduction of the expanded a. C. A. S usdys, we saw the majority of those in lowincome were paying about 25 for the plan before increasing subsidies came. Now we are seeing the largest growth in a. C. A. Enrollment is among those seeing zero dollar , when the plans were 25 we had no that they are zero dollars, there is a lot of enrollment. We are clearly there is an issue here with the perceived value of a. C. A. Plans. Moving forward how do you the a. C. A. Not thinking their plans are worth spending money on. It. The federal government there is a difference if you at a low income. 150 of the poverty line. There is a difference between 25 a month and zer a month. If you are living at that close to the poverty level. So it does make a big difference in terms of encouraging people to get in. Frankly, the purpose of it is much more to get people covered rather than to squeeze 25 out of them for a month. I think you see the results in that in terms of the enrollment. I think its got a good societal benefit. And we also in this process went through covid. Were quite scared about their health and wellbeing and felt qa real need to have Health Insurance. That is one of the reasons why we also had this bump as well. Now that people have it, if they can hold on to it, they will, unless they are caught in a state using a. I. To■u redetermination process. Remember, part of this is coming from those who disenrolled from medicaid, who were on medicaid during the covid period and then the states have kicked them off medicaid. We are talking about really lowincome people. We are going to have to even go ahead. You started this. Go ahead. Wendall, thank you for your point. In response to the question about whether it delays in implementation were due to needing time to implement the trying to change the c. B. O. Score. Dont think those two things are necessarily exclusive. I know a similar point was made a paper. From my reading from the legislative history, i would be curious if other people re alsoa big role in that decision to sort of shift back the implementation of the main coverage provisions to 2014. I would be curious to talk about it more with you. There are tons of other comments everybody on the panel would like to make and has made, even on the subject of time limits here. I want to thank you for being here. I get in the last word. I would point out a couple of quick things. Sales versus service. One thing to sell the legislation. Another thing to make it work. There are problems in assembling majorities. Real majoriehe first thing. The middle thing, and last thing. Everything else works around that. You cant assume a majority by saying this stuff will be great. You have to count the votes an keep them there. And people lose their jobs otherwise. The other thing about c. B. O. Individual mandate and other a. C. A. Provisions its like love story, never having to say youre sorry. They do it at the front end and dont bother later on. Thats more than enough. Dont kn a snipe hunt or a ghost chase. This law has■8 a ghost of a chae of continuing into the future. But in the apockry tpal quote which is not accurate, asked about the french revolution in the 1970aid too soon to tell. He was talking about the student riots in 1968 in paris. Its a i goostory. Going to end our story today. I thank you for coming. Thank our wonderful panel. Hope you come back again. [applause] [captions Copyright National cable satellite corp. 2024] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy visit ncicap. Org] ■s■■