Good morning. I hope you enjoyed the dinner last night are bright eyed and bushy tailed this morning. I have a couple of panels in the wings by chance. Rumor had it that i did. I see them coming. There is a handwaving. Very good appeared its good to see you. I was going to have to do a monologue for an hour. That wouldve been something. How are you . Grab a chair. We are now going to have a debate. We are going to have a classical republican versus democrat debate. It seems to be the time to do such a thing. Weve got repeal and replace in the wind and a very polarized nation. This is impacting ocelot. We thought it would make sense to invite a couple of representatives from the left and right. In terms of format, let me provide introductions to these gentlemen. We will out each of you to make a statement, maybe three or four minutes to provide your perspective on where we are in health care and then we will talk. Been a guests has couple of times. Ways inade his mark in this city working for both the Obama Administration and the drafting of the apparent aca and before that with the clinton administration. Is wellknown and very much a democrat. Pollet to represent that in our polarized world. Lanhee chen is a fellow at the hoover foundation. He is one of the top three leading voices on the right in terms of health care reform. Rubio an advisor to the campaign. You see his writings everywhere. He is a superb speaker and a good gentleman. With that, why dont i join you. I will let you go first. Regalis with your thoughts. Regale us with your thoughts. Chris jennings i do feel i should go last since we are in the minority right now. We have a little bit of energy now thanks to the republicans, which we appreciate. It usually when they are divided among themselves, its not because we are good at all. A vision and dysfunction that only does one good things for republicans, it camouflages hours. Rs. Ou i think you see an extraordinary time in the health care debate. You can talk about the polls and asked, it is significant that there was no other issue that pulled as high among voters as did health care by twentysomething points in virginia. There are cross cuts on this that are probably necessary to look at like economic security. Care really health dominated the domestic policy discussion this year and the political one. That was done as a consequence and result of an almost yearlong debate in an attempt to repeal and replace, which from our perspective we are pleased failed. That, you have a big debate from repeal to replace all the way to single they are. The democratic race is moving in that direction. There is frustration on both sides about our Health Care Delivery system. There is discourse and attention focused on exchanges. That represents 8 of the marketplace. Most people get their health care through their employer and 92 of the Media Coverage is on the exchanges and the individual marketplace. That filters a misperception of what our Health Care System is and what the challenges are. I think the big issue among the public there is frustration with complexity and outofpocket costs and that is a huge driver of the debate today. I think canada to only focus on exchange on any level are probably missing the vote on having an engaged discussion with the public and how they are thinking about this. That, the debate around the Affordable Care act has anchored the discussion. Look at almost everything that has been focused on, i like the last discussion. It validated and affirmed what we know in this room, health care is as much local as it is national and it is affected by both. There are huge differences and dynamics at every level. That filters into the political discourse as well. I will stop with this in turn it over. Lonnie. Where we are today, i would say the marketplace is not as bad as some people think. The irony of the withdrawal of the costsharing reduction payments mean that more money is going into the system to subsidize at higher levels. People can buy gold and bronze plans for much less than they would have their subsidize. Those who are in poverty are being exposed to high premiums and low benefits. That needs to be addressed. I would predict the markets and insurers participating will have a good year in terms of revenue intake. It doesnt mean its perfect. Healthcare is here needs reformed and thats why we all have jobs. The title of this panel is the saga continues. Rather than a star wars movie seems likely been to groundhog day with a star wars. A few observations. The first is that we went through a tumultuous time when republicans were coming at the problem from Different Directions with the same outcome. That predicts that did the same thing again next year. Were likely to see a similar effort next year on repeal and replace of the ca empire because of the political and parroted. If you look at Public Opinion polling or with voters in particular youll find a majority of them, literally still believe the top agenda item for congress to deal with his repeal and replace of the aca. If you think about the echo chamber that members of congress are getting in their home district they hear the ac is a problem and something has to be done. That suggests that even though they went through a lot of difficulty in dealing with the aca, they still feel a strong motivation, desire, and need to do something. 2018 and the tax reform debate, that will wrap up in december or july, depending on who you ask. It wraps up before we get into 2018. But i think we come back to discussions on the future. There is a policy issue here there are concerns about where things are going in some of that is in the marketplace. Set a huge number of people were talking about. Some cases do make for good media. Using stories about rapidly increasing problems also the quality or nature of the plans are changing soon have higher deductibles and less access to physicians. Those are Problems Congress the to deal with. Ideally in a bipartisan matter. The Energy Reason for bipartisanship right now. The second observation is that were an interesting time with respect to the healthcare on the progressive left. In my view, its interesting how quickly we have gone to a discussion around government run single payers, and the reason people call it Different Things because things registered differently. Medicare for all does better than singlepayer. That seems to be the way to talk about say dont scare people into thinking were turning into a european country. Now its interesting how quickly the discussion has migrated. Because the next election is never far away, the reason people are migrating is because will get to 2020 ahead of the next president ial election, in order to be successful as a democratic candidate for president needs to have been there early than other people. Thats why youre seeing this dynamic. Its remarkable that we havent had more earnest of a about singlepayer systems in the united states. We will see that debate. We will see that discussion we will see a significantly as we move into 2019 and approach the 2020 election. Republicans, would they settle in terms of what they wanted for the aca . More and more republicans agreed the way forward is emphasizing themes of federalism. He saw this in the past proposal of grandma cassidy. That focused on giving stays greater freedom and flexibility in the form of a block grant. And also loosened a lot of regulatory structures. I think it was probably too far, too fast. But it signals where republicans will be comfortable. If theres anything it exposed is that republicans dont agree on a lot when it comes to healthcare policy. Its a healthy thing to have disagreement and think about the future of healthcare policy in a thoughtful way. If you are to pull 100 republicans in congress, one thing that we get the most support is federalism, greater responsibility. Whether the foundation is the Graham Cassidy legislation or loosening the requirements of section 3032 waivers that allow states flexibility to design their Healthcare System so long as it complies with syria and benchmarks the ac establishes. Whether it is broad or narrow, i think well see effort on the right to migrate the discussion to the value of federalism and healthcare policy. I think its an interesting time because healthcare is never that far away from the center of a discussion. Theres a discussion about where republicans put into their tax package repeal of the mandate. When he makes healthcare and tax debate, bad things tend to happen. Its an interesting time. We will see a lot of discussion around healthcare. The republicans made a promise to repeal and replace. Weve seen their efforts to uphold that. Skinny repeal, Graham Cassidy. I want to break it down. There is a lot to the Affordable Care act. And we need to look at a little bit. All of those republican attempts included provisions that wouldve had the effect of rolling back the expansion. Why . I think there are a couple of reasons why. The notion of putting medicaid on a fixed federal medication has been around for a long time. Thats probably motivated by two things. One is a sincere sense that the federal obligation for medicaid is growing. Relatedly, theres a sense the program has gotten to break and that has to do with the expansion of medicaid through the aca be abroad and its good. Whether its a fiscal issue, 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 the aca, 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. The coalition is more limited than we thought. But all the attempts included that rollback. And possibly be increases slated because you get to the rollback that the future 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 . Is fair to say nothing is free. So we need to look systemwide to figure out if theyre not absorbed by medicaid where they observed. Theres another issue just which is the most effective way 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 of variation. Theres an argument to be made that medicaid is consuming a greater percentage of the federal budget. Is that a useful expansion of federal spending . Wes would argue it is and someone argue it is in because theres more effective ways to get there. Is that doubletalk . 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. The second issue medicaid when you look at the Media Coverage of legitimate policy problems raised its largely been focused on the exchanges. The Medicaid Program expansion, slashes that was 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 about this. Republicans needed offsets to reduce some policy they wanted. I would argue, im pleased they strategically made heirs but not to go just to repeal the expansion but to cap growth of the Medicaid Program. That brought in different people into the argument. For these reasons, i think it was a huge mistake. The last thing, you often hear medicaid costs and growth is outofcontrol. But on a per capita were growing at a very low level. 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 happened was suddenly the media focused on this debate and the way they hadnt. I republicans who revealed this many times didnt feel that 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 okay 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 the two parties with answering that question, is that a right or privilege . 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 big criticism they have is it and cover everyone. Which is sweet, i like that. 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 all republicans 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 got from that. Not from your people, my people your people are very supportive. It was not surprising. You can come over to our si 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 a be moving towards that it would be different. We dont even have that, theres more disagreements the fundamental terms of art. 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 costsheriffing cost 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 oall of exchanges . Issue i think. Answer that in light of the recent open enrollment where the numbers are higher than they have been in the past. I think that it ended up being a binary discussion. In an ideal world, yes, you would just go and fix create 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 nonsubsidizees 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 affordable a affordablity 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 workment we have 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 republicanned 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 dieing 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, not reinsurance polls. You should be talking about stablization, not reinsurance pools weapon need to find some Common Ground on this area, and i think there is. I talked to republican and democrats. Look, the whats the ma program . We have a reinsurance mechanism. Sunny because republicans want tote 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 buyin, 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 maccontract, 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 largescale 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 thing 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. 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 offsunsets 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 stateses 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 shake up 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 about 2018, 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 wait, the other good thing about the election we may say more states expanding medicaid in the next year or two. So watch that, particularfully 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 lonnity. 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 thedocks 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. And they dont get medicaid, benefits are going to cost more than anybody can afford. We dont get to that point. Look, i think that is that assessment is right in part because we have this relatively opaque Healthcare System. Right . Where 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 youre right, not particularly illustrative of the of what is really happening in terms of care delivery, the value of care delivery. I mean, all people are seeing is theyre seeing a premium and seeing the associated elements of the plan. Thats 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. Theyre within the control of other people in the system but its not were not having that discussion. I totally agree with you. But 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, and policy community carolina more and focuses much more on the hospital son consolidation and Health System consolidation. Its becoming almost a you can kind of feel this whole issue of market consolidation, politically getting a little bit more juice. Its underneath, its still a little bit underneath the action phase, but im signaling to you a little bit more encouragement from actually i think both parties are interested. The Trump Administration certainly second 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 ill to the it back on yall. The question is once a policymaker conclusions its a problem, the question is, what is the policy intervention to address . And other than, like, enforcement of competition rules, et cetera, like that, people dont have a lot. So if you have idead idead therd be a lot of policymakers both in and out of the executive and congressional levels, quite interested in talking to you. Heres ooh thought, eliminate fee for service in medicare. Well, i mean another thought. Make Medicare Advantage be the default and seniors have to enroll into original. There are thoughts on the table out there that would drive to a better model. How into woo 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 mma plan and that part of the country . Not 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. Lets be real. The second issue, though, is look, do think the ma marketplace, we have a third of the population in medicare already, tremendous growth notwithstanding the reduction in payments, theres your trend line looks pretty good. Additional incentives, i think on the republican side, no 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. It would be a mistake not to 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 the band 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 ways 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, and to a certain degree even if what hey have notice particularly efficient, they still like 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 theyre 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 betterment we have to improve care. We have to deal with safety issues, people are dying as a consequence. We have to i mean, i was just talking yesterday, to err is human. The issue was late90s. Projected probably wrongly, who knew, but 98,000 people are dying as a consequence of poorly coordinated care. You think that number has declined . Even whatever the number is, has declined since that time . 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 itch think you all can provide a leadership role in that regard. What is the symbol neither of you are Bernie Sanders but were you, what approach would single payer advocates suggest with regard to 30 waste . Well, they heres the thing. They conceptualize that 30 being totally focused on insurance companies. Administrative. At mr. Tive colorado, not the case administrative costs and thats not the case. Think politically their argument has traction with some people. Some people look at it and say, well issue dont understand why private insurers are involved in this. So, 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 have all si speier 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. Yes. 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 . Why the democratic view as to Medicare Advantage. So, walden said there are remain democrats sort of opposed to Medicare Advantage this, 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 i theyre 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 wasnt them and particularly disproportionate in urban settings, are not as hostile to ma that hey had previously. Now, does that mean that if there are perceived overpayment us or if there are real problems with coding and et cetera, et cetera, they wouldnt say we should do more overerr 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. ll repeat it. [inaudible question] not to be rude but your questions the audience knows that to do with duplication and [inaudible question] [inaudible question] [laughter] [inaudible question] i think your reaction is possibly, yes, yes. Yes. [laughter] on that we all agree. We agree with you completely. Has to do with the Unnecessary Services due mix qatif services, et cetera, unwarranted variation, couldnt agree more. Other questions. Have we got a little more time . Theres a david joiner hand. Were 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 speakerred throughout the course of the i came away with a certain sense of discouragement about what to expect from the administrative side of the equation, the various agencies, because of perhaps flight of people who traditionally have held the pieces together. One thing 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 thats realistic. Well, let me just start with my assessment which is that i think there are a lot very high quality 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. Think if the president goes in the direction people expect him to go in, in terms of his nomination nor next secretary of hhs i think alex is qualified and a very good leader for the agency. Im not dish dont have the same measure of concern about the people in those roles. What i do have concern about a little bit is what in the overall direction is going to be and what their marching orders will be. Im not sure theres been a ton of clarity on that front. To the degree may have been hostility toward the Movement Toward value, i tend to think that was focused more in the form of the person who sat in the secretarys chair previously. Which is not say that that is a very important role, and so if alex azar is the one sending the signals well continue to see Good Progress made. There are 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 good 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 reason we understand, but the daytoday operations of the exec consecutive 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 youre a stakeholder. 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 bad is bad. On that happy note, thank you, guys, very much. Give the panel a big round of applause. [applause] i believe we have a breck of some number of minutes. Yes, please enjoy a 15minute break, and the regency foyer. [inaudible conversations] thank you so much. All right. Good morning. Good morning. Thank you, cathy, thank you, don, thank you, everybody, for having me here. Im mat salo with the national soaks of medicaid directors. We just finished our only annual meeting and eye comparedded by today is veterans day and means all of my kid are off from school in daycare and i had to make arrange. S to get here but this is an important opportunity and i was thrilled to put the pieces together to make this work. Honestly, anytime i can talk about medicaid and people actually listen for more than three minutes is
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