Transcripts For CSPAN2 Health Care Replacement Bill 20170317

Serving a fairly lengthy prison sentence of a one appeal. And mr. Steinberg was convicted but then later overturned after an Appeals Court made a ruling that made a much harder to convict someone for insider trading. The next panel will be underway promptly fell. It is about repeal and replace with what . We have a little bit larger Panel Moderated by 1n of the Staff Writers that specializes in health care. Bill cassidy is a republican senator from louisiana who authored his legislation jill barton is a republican congressmen from texas the former chairman and currently the vice chairman of energy and Commerce Executive Vice President for Public Affairs at Americas Health insurance plans and of principle you may have heard his name spoken recently as the former hhs secretary during the bush administration. Thanks for being here today. We have a fantastic panel with of politics of epo and replace it is a busy time but think we are waiting just a moment for congressman barton and unfortunately dr. Mcclellan could not make it today but we have a lot to talk about for by want to jump right then it is the very busy time in washington for those working in health policy. Only a week ago they put out the legislative text of their plan and monday 24 Million People could do lose their Health Insurance coverage under the plan. Thinks speaker wright and said he is planning to bring this to the floor for a vote next week so it is a timely panel part of the first question is the of burning question. Can this pass the house . Clearly i m on the beach team. As the speaker likes to say there are two more committees with their are concerns clearly. Dino these they are my patients and that current structure of making 60,000 does not get the adequate assistance under the house plan and i am sure that is one of the concerns on the house side because also some things on the senate side. Sitting there will be an opportunity to speak on the medicaid side and there is some concerns expressed for the Freedom Caucus and other members with the lack of work requiremes as well as ending the match for the expansion population. But they still intend to move forward next week but the idea that the rules committee cannot make changes and improve the bill that is part of the legislative process. So that sausage making process but what they are trying to do is improve the bill. Is good for everyone trying to undertake the exercise. Can Talk Health Care without politics but we look at it as an opportunity the individual market has been challenged that is why it has been addressed in the first place. A Good Opportunity to bring shortterm stability. We hope it can move forward. I would like to dive deeper into what is going on with the moderates and the conservatives. But dr. Cassidy, half dec the fight play out . Changes to medicaid to freeze new enrollment from 2020 up that 2018 is that something moderates can accept . I know there are changes to the tax credits to make them more generous to lowincome or to the seniors. Howdy find that balance that both groups can except . I will push back of a little bit how you frame to that question. Because it is implicit that once inside as a conservative approach and the other has a moderate. Conservatives are about fiscal responsibility. So whatever we come forward with must have fiscal responsibility. Had an author that i authored there are three myths about obamacare but i will tell you the truth. Number one americans are already entitled to health care. Congress has established that. And we will pay for it for a climate doctor working in the hospital for the uninsured and as long as those doors were open asthmatic come as schizophrenic, diabetic, ove rdose, a car wreck, a beach reach. We would treat. It is not free. It is passed to somebody in day he made the policy over here in acknowledged that. So congress has already entitled people to care that will be paid for. Then is it better to give coverage where diabetes is managed as an outpatient that they come to the e are episodic the . Plywood say that the conservative responsible solution is to give coverage. The only way to control cost is appropriate coverage. This is something which empowers the patient. So why push back those of the fiscally responsible conservative approach. I do think that we will find Common Ground but just have to come to a common understanding of the fax. That is a process we are working through. I am glad that you made it congressmen. For once i am later than the senate. [laughter] we are talking about whether the house package to replace the Affordable Care act to pass the house seven like to hear your perspective. We have a lot of what this is why have to be careful what i say. And television cameras. I am part of the with team with a team going to the Budget Committee today and i have to say that there are a lot of undecideds. It decides what the president decides to do and to support the package as is. If we dont make changes then it will not pass the house. What type of changes quick. There is a division, uh the conservative faction that thinks we need to strengthen the bill and restrictedicaiexpansion program not allowed continued expansion with an amendment to do that and those that think there should be a requirement and there is a lot of concern at as figured would eliminate the essential benefits package. So those are the three big things. Concerns about Medicaid Expansion, the requirement for work and healthy adults and what was the third one . Laugh laugh the restrictions or elimination. Nobody in the house on republican side that does not want to send a bill to senator cassidy and his colleagues. We were talking about the balance between some more moderate or conservative members of the conference. So coming to that medicaid amendment i was speaking last night with the congressmen who said that moving vat 2020 days up at 2018 was a nonstarter. They both used the same board. How do you bring them on board quick. I would explain what theyre really does berger doesnt take anybody currently on medicaid as a healthy adults, off. Id just says in the states and have expanded medicaid they cannot continue to expand their population beyond this calendar year berger does not kick anybody off but as of january 1st january 1st, 2018 you cannot continue to add people to help the adults healthy adults. But as state surgery go back to the traditional match 58 42 under that the federal government paid 100 percent of the cost until this year is that 95 percent in phases down at 90 but then stays there in perpetuity. So the healthiest group of adults on medicaid get 90 percent match with traditional recipience disabled, women and children , the states pay on average 42 and the feds pay 50 percent. It is not the draconian program that some of the opponents proclaim it to be. No republicans voted for this when it came to the house and senate. Why we think we have to protect the Program Better essentially was a bribe to the states texnd t population to young and healthy adults is beyond me. Cinch to help last night bush uc more hesitation from those conservatives or both greg. Theyre only four people and we are two of them laugh laugh so its not like diane flogging volcker congress. Bill whole congress. But we all wanted to pass some of us want to see it improved first. There is a lot of good will for the of leadership. We enter stay and their dilemma and want to work with our president with basic principles. I want to last. You have a senator right here. I will get to him but one more question with the house where the action is. How big of a role does the lighthouse play right now or should they be to bring this through to the vote . I think the white house is key and were very fortunate that to of the key white house intermediaries time prices former Services Committee and director omb is one of the coaches on the Congressional Baseball Team and a key member. Most presidencies to that extent have experience on the senate side did in this case even the Vice President are house members. We have a lot of interaction which i think speaks well for a the end came when it comes time to make the final decisions. They know the rhythm of the house and the president can intervene in a wave with a positive result. The Campaign Said he had four goals to continue to cover folks those with preexisting conditions without mandates that is what he was elected on and said repeatedly. Said the president is committed those that have suffered over the last eight years in the economy that has not worked for them. But then come up with a good product. Now have to press you on this the congressman has been pretty optimistic getting this through. Will lead makethroug the senate quick. We dont know what they are sending over first. There is more concern on the senate side that coverage continues. It is hard in our country to offer folks something given time to adjust then withdrawal. I also point out to the we have lots of programs to help people get health care. Medicare and medicaid veterans, and try care, disproportionate hospitals, i could go one. But there is a group tom price calls of all burbles for economy to much to qualify for medicaid but if they make 15,000 per year they dont have the money to put up as the contribution to sponsored insurance. So the president speaks about the vulnerable slows are there. There is concern on the senate side they have the same advantage as somebody making 180,000 per year with the tax code subsidizing the premium. The employer sponsored insurance benefit is only five case of will begin that benefit as well to those who are lower in complexnd feel thad to have 20,000 per year. So the senate would amend this and with the deadline getting this before the april o recess. It is not going through committee. May have judge gorsuch in the interim but senators are putting their amendments together n speaking among ourselves to get support and understanding. It will be amended and go to conference the leader has told us if we dont get it done and plan on staying over easter sometimes that is ready advice will sharpen their mind. What he as outlined so will day pick that back up to make it happen quick. Were always optimistic in the house but to see the senate act is refreshing spectacle. If they do make changes that is the normal process over half the senate was including senator cassidy somebody that served on the committee we want to get this done as they decide to participate in a positive way and if that happens in the American People will be much more comfortable with the Affordable Care act. Want to give them a chance to take a breath so under this current plan what happens to the Insurance Markets. Before i get to that hearing here reminds me of what Newt Gingrich used to say to the freshmen democrats are the opponents but this senator is our enemy. [laughter] but as i said before we are very optimistic we can have both shortterm stability and longterm improvement so working together collaboratively can fix the of market with any Company Needs is certainty and clarity and one thing that health plans need is that lovell of certainty because the Product Development cycle is fairly well set in the window is closing very rapidly for products to be introduced to the market in 2018. A lot of troops to jump threat the state level and Actuarial Research that goes into pricing and planning products for the market there a number of positives so looking at the proposed rule from a few weeks ago into bringing stability to the markets to close the loopholes to drive up the cost for everyone. With the employment market open enrollment period. We would need. So i think in the next month or so if there is a package folks can plan on him to start the ane process with the review, we will see i think some positive movement. So, the calendar moves is one of the biggest concerns at this point. Some of the things we look at it that can be improved, senator cassady mentioned one of them on the tax credits side is a ageadjusted and that certainly can be effective for some but when you look at actually affording health care coverage, if you only have it on age, there is a block of the population that will hit consumers when they cant afford it. They are too much to be eligible for medicaid and tax credits simply cant cover the policy that they choose, so we hope at some point there can be an improvement that is ageadjusted but also has an income component and we think that will deliver the resources folks can use to purchase effective coverage. Coverage. Can i comment on that . One of the things he said i dont think many people realize is we had an election this past november and all republicans i think without exception were promised if they one and we controlled the government that we would repeal at a minimum repeathe minimumrepeal obamacars said we also wanted to replace or reform it. So, when people go to vote in the off president ial elections next year, their health care and cost of coverage if they have Health Insurance are going to be a key decisionmaker on who they vote for that as he pointed out, Insurance Markets dont operate on election cycles and so i take is pretty well baked on what the Health Care Costs if you have Health Insurance coverage is going to be and the political system simply cant operate as quickly as the consumer decisionmaking when you go to the polls next year youre going to say am i better off or worse off with my healthcare insurance and the components are the costs to you and whether the plan meets your needs. X. Cheers healthcare costs are going to be based on the Affordable Care act, not on all of these reforms in the things that we are working on right now. So we probably hopefully are going to have a much more affordable and much better quality access to care system but its not going to be for another three years or two years at least for the minimum and the election is going to intervene before that happens. Figure is another positive provision in the bill that can affect the race very quickly. The Health Insurance tax that was in the Affordable Care act originally, 110 billion in premium taxes on many Health Insurance plans, so small businesses, seniors on medicare. That has been delayed for a year but is now repealed in the package moving through the house and on average that is about a 3 increase in premiums just on that alone, so that is something that can deliver shortterm benefits but another. And if the requirement that has to be provided, so some of the things are going to have an immediate effect. Let me ask one followup and that is about the continuous coverage required and there are some discussions on the hill about potentially dropping that provision from the bill. But obviously it is important when you couple it with preexisting condition protections and im curious what would happen if that were dropped from the package. Its no seek with the mandate is one of the most unpopular pieces of legislation weve seen in a long time. How effective if one is to bring people into the market is under some debate. Some people think that it was defective and some people think it didnt have an impact. What we know whether it is Health Insurance or Car Insurance or home insurance, you cant have folks that just by coverage when they actually need care. Its like buying Auto Insurance after you have had a wreck so to keep the cost down for every one you have to utilize. Someone who needs treatment for whatever behavioral ailment, whatever they need you need folks that have insurance to cover the cost then you also need folks that have insurance in case they need to seek care at some point. That is how you balance out the risk pool and lower the cost for everyone. So if you have a system where folks dont have the mandate but can still sign up for coverage when they need it, its going to raise the cost for everyone, so there has to be some type of a continuous coverage incentive. The 30 premium charge for not having continuous coverage is a start. We think it can be effective and help mitigate the mandate, but we think we can be constructed and find solutions that do work because we share the same goal as the congressman and the senate that we want lower cost and better quality and more affordable coverage for every american and we know that in order to get that, you have to have more people, those that utilize kerry and those who dont, so we think that provision is important, though we certainly want to have a constructive dialogue. There is another way to get back by the way the patient freedom act the plan in Susan Collins eyes, and i am blinking on the other person, it is to allow the states to automatically enroll folks and in the house plan, it appears that provision is allowed. They could say listen we are going to give you credit for the premium and you will be enrolled unless you call and say you dont want to be. No one says it is that as a mao just end up on part and a few cranky folks call up and say i dont want it. But as a rule, you do that. We had an Insurance Company model what i would if we had the automatic enrollment and they said that by itself with over the premium by 20 even still keeping those that are less healthy so there is a mechanism that is both in the patient freedom act and by the way just endorsed i think it was on the Health Affairs blog post they said it should be looked at as a way to restore the balance without a mandate. One last big picture questi question. What i want to talk about is some of ththesum of the sort ofm priorities that i know are on a a lot of republican wish list but havent made it into the package for the reconciliation rules and whatever else and i know tom price was talking about some of these last night for example the Health Benefits and things like that. Theres a very long list, but i want to ask at least in terms of the changes that might need congressional action, things that might need to go through regular order what do you think are the chances for Something Like that to happen in this congress, the socalled third phase of Health Reform how likely are we to see big changes there . I think that question remains to be uncertain until we see the effect in the senate because there are certain components in the house that arguably may not make it through but that question cant be answered until she makes a ruling. But i think it is in th the facs folks talk about and the administrative phase is critical especially as you see the construction of the house bill. One of the key components and fundamental changes that will come about because of this legislation is the change to medicaid and that is something theyve been working on for a number of years that will require a lot of work from health and Human Services to implement and i think that is where there are some open questions on flexibility and what other pieces could be part of this, but disposal in order to put it together you need not only the pieces from the house legislation but also the administrative portion as well. In terms of what happens in phase number three, it is a threshold and what is coming through so i think the idea now is they will be voting on the Liability Reform or wildest changes or Association Health plans but whether those can get through the senate, that is an open question. There are some packages that will have to move through the senate and the house on the healthcare side. We havent talked about the medicare extension or other pieces that are going to have to move through that can provide vehicles for some of those changes but i think what youre going to see is there will have to be able to subsequent steps in order to implement the legislation and do it in a way that their vision is around it. Do you want to jump in on this . Im not sure what i can add d to that because theres stuff like the essential Health Benefit that would probably not be judged to raise or lower expenditures and so therefore it doesnt pass the rule. Can we get a threshold but step back a little but ideally we have something that is bipartisan and i think it is fair to say theres been nothing overarching in our society on a bipartisan basis and i think obamacare is the latest example, so ive spoken to democrats and would like them to come in and influence the product. Clearly if some day that they would have great leverage. That said, when we introduced the patient freedom act, Chuck Schumer criticized it before we introduced it. We had the only copies so to speak and he was already criticizing it so there is a big dynamic on their side. What i tell my colleagues though is this isnt about politics, its about the patient, its about somebody that if we get it right would have a happy and full life and if we dont, wele will have a life of decline. That is what this is about and so i hope folks dont just sit back hoping for political advantage but step forward as the patient. Anyone else want to jump in on a . The packages moving through the house addresses a lot of things in the two areas that i think is a good thing. One is the Employer Market is the most 180 Million People who get their insurance through their employer. And this isnt to say that it cant be improved certainly on the cost side it can be but its been relatively stable the past eight or ten years we have seen historically low cost growth so i think that by leaving bad, that certainly was a positive thing. Leaving aside medicare for the moment, that certainly needs improvement in the longterm as well but Something Like Medicare Advantage delivered better value and Better Services and results both for seniors and taxpayers and i think setting that aside for another discussion was a positive thing, but in the third bucket to spea speaker speaker r price talked about, one area we can addresses the rising cost of Prescription Drugs and if you look at the headlines over the past year just look at the consequences that the costs have on families is enormous. So introducing more competition i think is important especially when you see the cost going up for a greater thafar greater thn the health care system. 25 of the costs are now Prescription Drugs. We released a bit of research that showed the breakdown of the premium dollar and a Prescription Drug costs now account for 22 of spending and that doesnt even include the Prescription Drugs that are dispensed in the hospitals, so that is enormous and growing and i think there can be Bipartisan Solutions to address the cost of the drugs that can deliver more competition and choice and lower cost. I would like to comment on what the senator said for things to last they do need to be bipartisan. Hes right on that. But since this happened in a very partisan way, the creation is almost certainly going to have to be changed in a partisan way so there are many members of the house do think we ought to give the bird to the byrd rule so to speak. [laughter] because we dont see Democratic Senators all of a sudden having an epiphany deciding to work. Through the good grace of senator cassidy and others, there is always that chance, but we are very skeptical in the conservative wing of the house that youre ever going to get to the third bucket so to speak or the thirdbase. Hopefully it will happen, but i wouldnt bet my last healthcare premium dollar on it. I will say that the statute you cant just kind of waved it off with that said i would also agree on what joe said. Which is we shouldnt bank on whatever we put forth now must be able to stand on its own and that is true. With that we should open up for questions we have a few minutes if anyone wants to jump in and i just ask that you introduce yourself. My question is when we were going through that process to cost frecost reform or bending t curve was one of the discussions and the current bill has a lot of discussions and a lot of proposals on coverage reform that we are not really addressing the actual medical cost so what are we doing in terms of the programs handle this today and the cost curve or bring it down . Hopefully if you recreate the True Health Care market with lots of competition and Consumer Choice thats going to bend the cost curve because consumers will pick plans to meet their tr needs and that they think are affordable. Its difficult to create age grew transparent Healthcare Market because so many people get their Health Insurance through where they work but if we can create such a market, we are not doing away with the individual exchanges we are simply not making people have to participate and i think that will happen if you reform the benefits package requirement, that is going to bend the cost curve as it has already been pointed out you will eliminate the taxes and that will take the cost curve down. And i think if you eliminate a lot of the red tape that the doctors and providers have to contend with, the efficiency improvement will bend the cost curve down. Lets speak about medicaid, first. Part of the cost driver is the states incentivize the State Government and for example if they recover waste, fraud and abuse they have that portion that is due to the government and it is a disincentive to go after waste, fraud and abuse that the hospital into the state uses it to draw down federal dollars that the beneficiary payment addresses that just as the state goes to the managed care company and sai that you g. Amount of dollars the federal government goes to the state and says you can get a little bit more for someone that looks like that. By the way, the administration went to rhode island and gave them a block grant and rhode island brought the cost down and empirically this worked. There are several aspects to this. How do we increase Competition Among Insurance Companies i think we are inviting competition to return that the regulation for flexibility so that can lower cost. If you have only one Insurance Company the costs are going up. Second we have to lower the cost of healthcare. One thing we have on the patient free tomac this price transparency. Theres lots of examples about how the pricing mechanism keeps the power in the hands of the provider. We need to give it to the patient. One example, with lasik surgery, laser eye surgery candidates come down over the last ten years as Everything Else has risen. Theres over cost because of the total price transparency. So i think that is another component. I could go on but i will stop. Senator cassidy didnt say this in the house. Thing with the jewish federations of america we represent a great deal of nonprofit providers across the country including louisiana and i wanted to dig a little deeper into the recent score saying that there would be a 25 cut with medicaid estate that should be the current bill to go through. We have great concern about what it means to the provider cuts as well as the Economic Impact to the states. We do know of one Major Hospital not unlike the one who is thinking about pulling a 1 billiondollar contract in the city of cleveland building a new hospital because they fear that they are not going to be able to make ends meet. Can you talk about what the per capita cap might mean yes it is going to contain the cost but it might be the provider rate as well as the Overall Economic effect for the nation. On the Medicaid Expansion, if the broad level plan someone is getting about 4,200 to subsidize their care on average and on the traditional medicaid about 4,000 these are the six patients to use it on the Medicare Advantage if you pull up the managed Care Companies last year they were getting on average i think 6,000 this coming year, 6300 so on the Medicaid Expansion programs, if you do apples and apples, a 35yearold on Medicaid Expansion and the managed Care Organizations are getting about 107 on the actuarial value blue cross policy. Let me repeat that on the Medicaid Expansion look at the filings. They are getting about 107 of what they blue cross actuarial value policy would cost. They are paying medicaid rates with a medicaid Provider Panel and getting the 107 of the actuarial blue cross policy. If you speak to me about the great, i will tell you for traditional medicaid pays below cost disincentive rising and even eliminating the ability to see such a patient that by the way just parenthetically some of that is a problem in the states. There is one state i know of that i think is illinois in fact i know is that pays its hospitals in such a way and providers in such a way as to incentivize the hospitalization. Thats wrong. Its bad for the patient and the fear. So if you will come o, the way o protect that is the state of illinois doesnt hav doesnt hae ability to pass the costs to the federal government but rather they get a budget and figure out it is cheaper and better to treat them. But look at the Medicaid Expansion, there is a lot of room to actually lower cost and preserve care and if it doesnt preserve care it isnt the fault of the federal taxpayer right now is paying the actuarial value of the blue cross policy as a