Transcripts For CSPAN Washington Journal 20161212 : comparem

the affordable care act. we want to hear from those in the medical field about how this has impacted your job and patience. for the first 45 minutes we will have a special line for doctors (202) 748-8000. nurses, special line for you, (202) 748-8001. all other medical professionals can call in (202) 748-8002. you can catch up with us on social media, on twitter. on facebook it is facebook.com/cspan. you, we areng to talking about the affordable care the current state and future of that law. we want to hear from doctors, nurses, other medical professionals this morning. we heard from the speaker of the house over the weekend about obamacare as he refers to it. here are a series of tweets from paul ryan. "obamacare is giving americans another double-digit premium increase, and fewer choices. obamacare, millions of americans only have one choice for health insurance, which is really not a choice. it is a monopoly." mitch mcconnell, the republican leader in the senate on twitter last week. "americans deserve better than the failures of obamacare. with tom price leading health and human services, we can deliver on our promise to replace it." from senator tim kaine of virginia, tweeting that it is imperative that the new administration and congress move forward on health care and not erase the gains made by the affordable care act. he tweeted that it would be reckless to repeal the aca and have a drastic impact on the american people. we want to hear from doctors, nurses, other medical professionals about how the aca is impacting your jobs. one of those medical professionals that is commenting today is richard friedman, a columnist in the "new york times." he is a professor of medical psychology at the wells cornell medical college. he writes a column today titled "mentally ill without obamacare." he goes on to say, "if president-elect makes good on his promise to repeal the law, he will strip millions of americans of the most medically rational and humane benefits they have ever had without giving them any indication what will replace them. the consequences will be quick and devastating. psychiatrically ill americans lose coverage will be worse to be treated in emergency room's, causing a meteor rise in health care costs." to read his full column, it is in today's "new york times." doctors, nurses, and other medical professionals. doctors, (202) 748-8000. nurses (202) 748-8001. other medical professionals (202) 748-8002. last week on this program we were joined by a republican congressman who is a surgeon. he talked about the burden the affordable care act places on doctors. here is what he had to say. >> i hear from doctors every day. i spend a lot of time staring at a computer screen and not talking to my patients. that is because the federal government has so many mandates and demanded so many things through the affordable care act, including what is called meaningful use, where physicians have to record all this data, it is almost impossible not to spend a lot of time at the computer screen. congressman larry bush on. he joined the washington journal last week. the christian science monitor in one of their lead stories this week, the headline, "how the gop may reshape health care." tomsing on congressman price, who was nominated to head health and human services. there is a picture of him there. the challenge has always been to agree on a replacement. that is the challenge for republicans as they look at repealing and replacing. republicans have not come to a consensus in the house. they seem to be generally settled on a series of points that were outlined in a document called a better way, which congressman price supports. it supports having pre-existing conditions covered and allowing young people to stay on their parents insurance. it would drop state and federal marketplace exchanges. under the new plan, people would be able to purchase insurance on the open market with the help of refundable tax credits. they all favor health insurance as available across state lines, and there would be greater incentives for people to put away the tax dollars in health savings accounts. this calls for specialized high risk pools. belth care rates would awarded to the states in the form of block grants. we want to hear from medical professionals, doctors, nurses, and all others that have current or past medical experience. we want to hear your thoughts on the affordable care act, how it has impacted you, your job, your patience. doctors (202) 748-8000. nurses (202) 748-8001. all other medical professionals (202) 748-8002. chicago, a first this morning on "washington journal". guest: -- caller: i was licensed in 1981. i have seen a lot of changes. i have been a registered nurse, and i have been a patient. i look at it both ways. the patient, i don't think care is getting better. i think it is getting worse. pushed.f is just being as a practitioner, i left nursing as an administrator. i think that more and more the emphasis continues to be even with the affordable care act to create profits. i don't think that health care .hould be a profit sector i think we should look at it as something that society has to provide for people to maintain health and wellness. host: when you say the staff is being pushed to the limit, are they being pushed because of new mandates and rules placed on them because of the affordable care act, or is it a staffing issue? caller: it is both. the affordable care act provides havinge what i consider to use it fairly often in my provides someone with a mediocre health care system. graduated, i had probably the full and of the health care. i did not need it, i was young. i had it. i was coming from a pool of people who were generally healthy. now with the affordable care act , i feel like i am a charity case. everybody is a charity case. you are better off having enough money of your own to be able to move around the health care system the way you see it. more importantly, you have to self advocate, which was not something that was true in the 1980's. thank you for your work as a nurse. elaine is from michigan. thank you. calling because hospitals are getting bunches -- bonuses for getting patients out of the hospital early. what is happening is patient that should be staying longer are being shuffled into long-term care facilities before they are ready, and this is causing the patients to suffer because they really need the acute care, but they are being pushed out early so the hospitals can get their extra money. if they are admitted back to the hospital within 48 hours, they get penalized for that. what is happening is patients theyuffering because really need acute care facilities to take them in longer. it is a circle going around and around. patients are not being cared for properly. thoughs this is as worked differently before the affordable care act? caller: absolutely. it was never like this before. hospitals now with their reimbursement are directly tied to patients satisfaction. if the patient's are not happy, then they get different reimbursement. they are trying to juggle that along with this cuts in the reimbursement as far as patients getting out of the hospital to get that bonus money. if the patient has heart disease, if they can get the patient out of the icu and into a long-term care facility, they get extra money for that even though the patient may need something. host: how that -- may i ask how that patient satisfaction is such a key factor in their reimbursement? how is that determined? is it just a survey they fell out after leaving the hospital? caller: correct. they have a nurse call them with a written survey to fill out. leaving thes hospital are sick and not happy. they are not happy about it. they are not happy about being shuffled out before they are ready. they are not given a choice about it. up. are told their days are out herebeing shuffled the satisfaction scores have diminished. so have the reimbursements. these sorts of surveys were never in place before the affordable care act? caller: not tied to reimbursement. now it is. it is a mess because the wages .re stagnant for nurses as far as nursing assistants, they are cutting back. they are outsourcing the dietary departments portrays -- for trays. hospital hass the to do to save money for profit. i don't see how they can unless they come up with a different way of reimbursement for the affordable care act. it is really going to be hurting. host: thank you for the call from michigan. (202)mber for nurses 748-8001. doctors (202) 748-8000. professionals, we want to hear from you as well, (202) 748-8002. these are the people inside the system that have seen the impact of the affordable care act. daniel is on that line from indiana. caller: good morning. a direct service professional for about a year until the end of the year last year. i saw a lot of the changes get implemented while i was working. one of the things i noticed. host: what does a direct service professional do? provide services to people with intellectual disabilities. we do a lot of different things. onfocus on counseling, also taking care of household chores, hygiene, all kinds of stuff. we want people to be independent, cognizant people. the impact of the aca was more promotional along the lines of the parent situation. i really got to see how the health care system affected patients trying to get services. this happened to be with the parent. this person really focused on wanting a smarter, simpler process. anytime you have the federal government involved with anything, the process is more stringent. the affordable care act seemed to bring families closer together. with 14 million people being given insurance with the affordable care act, the staff takes on more patients and it certainharder to focus specific patient needs. i saw that with the staff and my job. one thing i was able to do with these few days i work in this job every week was to put impact into their life. this is something that got thrown at me sporadically. it has not been a very good impact. people are not happy with the outcome of the affordable care act. i saw this. she mentioned the state needs to be quicker. with the federal government giving states money, that is not happening. it has not been the greatest impact we would have wanted to see. that is all i have to say. host: thank you. call from indiana. post, abraham as palm is the chief education officer and a professor of psychiatry at the university of colorado. in his column yesterday he writes, "in colorado the medicaid expansion halved the number of uninsured. now receivepatients medicaid, which has enabled us to add positions, integrate behavioral health to primary care, and add quality jobs. even though many private petitioners refused to accept medicaid, safety net systems stretch these modest payments into a network of benefits. in the 19 states that have not expanded coverage, the system is different. the kaiser family foundation observed that -- accounts for more than three fourths of that population. " doctors (202) 748-8000. nurses (202) 748-8001. other medical professionals (202) 748-8002. how has the aca impacted your job? amelia is a nurse in georgia. good morning. caller: good morning. thank you for taking my call. when i have noticed over the that we noars is longer have a lot of patients that come through the emergency room without insurance. over the years, before the affordable care act, hospitals had to absorb the costs of patients coming to the hospital without any insurance. gethe backend they would passed on to the taxpayers. now we have a lot of people with coverage. one of the things, i am a nurse, i have worked in the hospital setting and also for eight years at the insurance company. one thing is that most people do not understand that our medical costs are passed on directly to the employers. any changes people have suffered recently to the insurance benefits is directly due to employers changing and choosing bad packages for the employees. it has nothing to do with the affordable care act. the employer, who is responsible costs,ing your medical not the affordable care act. if you work at a particular company and you notice any changes to your benefits, it was your employer that made that change. it has nothing to do with the affordable care act. they have spread a lot of misconception and lies about the affordable care act. we will be talking about a lot of the issues that you bring up throughout our program today. most of our program will be devoted to the current state and future of the aca. we will have a roundtable with a wall street journal health care policy reporter, washington post policy reporter. we'll have two former administrators of the agency now known as cms, which helped oversee the implementation of the affordable care act. that will be our second panel this morning. dr. butler is calling in from portsmouth, virginia. good morning. caller: i have worked in both the private sector and public sector. i think the critical question is how much medical care reaches ts. patien you will see our country compared with 21 other countries, and we do not do so well. it is worth reading the work of senator charles grassley about thatbecause he thinks nonprofit hospitals have to be carefully examined in our that theo be sure money intended for the patient reaches the bedside, so to speak. host: can you talk about your hospital in virginia and how that is playing out? caller: i have worked in private hospitals and other states as well as in army and navy hospitals. that is why i recommend reading the healing of america. in the navy hospital and some of the va hospital's i have ccasionally been in, but particularly the military hospitals, it is quite clear in accounting how much money reaches the patients. you don't have problems of exotic administrative salaries, or $4.666.4 million million going to someone who is running a private hospital. under the law in the commonwealth in virginia. there is one comment i would make about virginia. law,u look at the virginia you will see it is the only commonwealth or state which has tax credits for charity care, which applies not only to doctors but to dentists and lawyers. if you google donations of professional services, you will see the virginia law which gives people a direct tax credit for taking care of people who cannot pay. if you want to fix obamacare, that is one way to do it. there are other ways to do it. way to do it state by state and very quickly. host: thank you for the call. stephanie isdiana, waiting on the line for other medical professionals. caller: good morning. thank you for taking my call. host: go ahead. caller: i have been in a physician's office for 15 years. i have seen the benefits of health care, the good and the bad. with medicare patients, the reimbursement rate is so low that i have seen my doctors have to triple their workload just to pay overhead and employees. i don't understand why people think this medicaid plan is a good idea. we have doctors in our local area who turn medicaid patients away starting in january because they cannot afford it anymore. on twitter, as we were having this discussion, his doctor is cutting a patient list of 600 people, now he has to pay monthly to the doctor. is that something you are seeing? caller: i have not seen that in my area. members who work outside of the state who have seen that happen. doctors have literally tripled their workload. they are spending less quality time with the patient. with all of the electronic documentation they have to do now, they don't have a chance to look up and speak with the patient. longeres are working hours. they cannot afford higher pay. it is not a good situation. the time spent on paperwork is something that the congressman on our program last week talked about. dr. from maryland. actis the affordable care contacting you? caller: i am a medical oncologist at johns hopkins in baltimore. with a cancer diagnosis, patients often need more than a diagnosis. there are some disadvantages. i think it needs some fixes. the ability and the health care a lot to allow our patients to receive not just oncology care, but fiscal therapy has been a real need for our patients. host: care and coverage very important when we have this discussion. so our costs. on twitter, costs are the problem here. do you have any ideas for driving down the costs? my understanding of what has happened with health care costs is that we have been able to control health care costs better under obamacare that has been done previously. itave been satisfied with for my patients. reimbursements have gone down for many reasons. i don't think it is only obamacare. there is a previous caller who talked about medicine mapping and industry we going to where we can make large amounts of money. i feel strongly about that. i'm comfortable with that balance. host: thank you for the call this morning. pat is in florida, a nurse. good morning. caller: good morning. i feel the affordable care act on mypositive impact role. i am a regional quality director , and i support 20 hospitals for national healthcare company. my comments are focused on the hospital setting. i agree with the past comments from some callers that the paperwork can sometimes be overwhelming. i also agree with the comment that we have seen a lot of our improved coverage for our hospitals in the emergency room. the affordable care act has promoted pay for performance. that is allowed my hospitals to focus on improving quality and safety for our patients. i feel it has been a positive influence. host: does that pay for performance include patient satisfaction scores that our previous caller was talking about? caller: it does. i would comment on those scores. they measure not only if the patient is happy, but if they received information about their medications at the time of administration, do they have information about what they need to do when they get home, their pain control, did nurses and doctors communicate well. credible information. host: do you think those should be tied to reimbursement? caller: yes. we have found correlation studies on positive responses to those questions correlate to decreased infections, mortality outcomes, and overall better patient safety. host: same question for you as the last caller. how do you drive down the costs that people are so concerned about? caller: improving quality and safety does decrease cost. theoved safety decreases length of stay and the amount of resources required to get that patient back to their optimal health status. effective, focus on evidence-based processes. you are streamlining your resources to their best capability. i also think the incentive is that if you're doing well, you are reimbursed in some programs at a higher rate. "we are already paying 39% of our income in health care before this year's giant increases in premiums and adoptable. it is interrupting us -- bankrupting us." reign incans cannot health care. it is too complex. universal health care is the answer." at computertting filling in the blanks required by the government to cover his ass." jim is on that line for other medical professionals. good morning. caller: good morning. how are you? host: doing well. go ahead. a couple want to make of comments in regards to some of the medical professionals talking about the processes through which they take their patients. the government cannot reduce the health care cost. they have not reduced health care costs. the only way to reduce health care costs in this country is through medical savings accounts. that is number one. number two, we need tort reform for these doctors. my wife is a registered nurse. the people she sees at the pain clinic she works at who have medicare benefits, the people are not taking care of their bodies. withroblem in this country health care costs rising is the obesity rate. you have some of people who commented that clinic for paying that are either disabled -- pain that are either disabled, won't work, or can't work and are getting medicare. we have a heavy load of sick people who are not working, and we are driving health care costs because we have all of these people on obamacare, which is driving up the costs. there are people that have a lot of issues. , and i feelssional for these people that don't have health insurance and have obamacare health through medicare. you will not solve the health cost issue. you drive down health costs with catastrophic health care and health savings accounts. that is how you do it. you get people off of medicare. you get them off government programs and back to work. as we said, republicans are debating various options for repeal and replace. among those contributing to the conversation, and a column last week in the "national review" was mike lee of utah, a person whose name is on donald trump's list for possible supreme court nominees. he wrote a column. "deleting obamacare from federal statute will only be the first step. republicans cannot wash their hands of the democrats failed health care reforms. we have a responsibility to fix. this means providing a transition for however many years for the market to recover and serve individuals and businesses with more affordable health care. this means in the best of many free-market health care repair proposals. people do not need heavy-handed government mandates. " what comes next is the topic of our them today. we will have two panels discussing those issues. we talk about health care from now until about 9:30 this morning. phone lines will be dedicated to viewers throughout the segments. linda from new york, a nurse. talk about your experiences in brooklyn. caller: good morning. how are you? host: doing well. go ahead. caller: i am a retired nurse after 40 years. it is important that everybody should be entitled to good health care in this country. the affordable care act has allowed people to do that. beforewho were uninsured would end up in the emergency room, which would cost more for the government than if they had their own private care physician. or the affordable care act is something that i feel is much needed in this country. i think what has to happen is we need to concentrate more on prevention. host: we mentioned at the top of our program that president obama is going to be signing the 21st century cures act, that mental health and medical research legislation that was passed last week. president obama and vice president biden expected to deliver remarks according to "the washington times." on wednesday the president will host to hanukkah receptions at the white house. more meetings scheduled for friday. in the evening, the first family on friday will depart the white house en route to honolulu, hawaii for their christmas break. time for a few more calls in this segment of "washington journal." we are talking to health professionals, doctors, nurses about how the affordable care act has impacted your job. peter, the doctor. good morning. caller: thank you for taking my call. what has happened with obamacare, it mandated -- let me say it is the perfect example of morning about the road to hell is paved with good intentions. this has turned us into more workersctronic clerical . it has corroded the actual art and practice of medicine where we interact with patients. i am a medical oncologist so i have to spend a lot of time with the patient. that is the most important thing we do as a physician. that is through thousands of years of development of the art of medicine. this idea that if you computerize everything it makes things better, it is making it much worse. see aes twice as long to patient is all these mandates and decrees that have actually -- because of all of these dndates inquiries -- and ecrees. it is turning this into a fascist enterprise. it subverts the practice of medicine. if you read george orwell's "198 4," it is really becoming orwellian. it is impacting our ability to interact and take care of our patients. host: one of the reasons that was talked about, all of this paperwork keeping things from slipping through the cracks, do you find that you have improved in that area? caller: no. it is much worse. it has gotten worse. what happens is you get administrative and political types at the federal level would think they know better than we do. they mandate all of these things that are peripheral issues and do not directly affect the care of the patient. the physicians and nurses and nurse practitioners can care for the patient by their own abilities and insight and education and experience. what has happened is peter systems, which are mandatory and -- computer systems, which are mandatory and orwellian and much more time-consuming and expensive, basically they are undoing thousands of years in the art and practice of ms. -- medicine. the government comes in and thinks they know better. they put in place this computer system between the doctor and the patient. host: let's hear from another doctor. dr. mark is in bethesda, maryland. good morning. caller: thank you for taking my call. i would agree with the previous caller. the computer systems were ill-informed in terms of how they designed the system. each computer system, each doctor, each hospital system is obligated to have a computer system. these do not talk to each other. essentially they designed this entire infrastructures so every hospital and doctor's office like myself has a computer system that does not talk to the next computer system. host: what is an example of that causing a real-life problem for a patient? caller: in my private practice i have two duplicate systems. i have medical records that have to be done on the computer, which is time-consuming and limits agent interaction. to ammunicate that referring doctor has to be faxed. there is no way of electronic transfer between systems because everyone is using their own different systems. there is an astronomical cost of having those systems. i pay around $30,000 to $2000 a year just for my -- $50,000 a year just for my computer system as part of a ca. there is a huge cost of this. it has not been affordable. the is unfortunately travesty of aca. patient care has been worse. patients have been shouldering more of the burden. havew some professors who called him before do not see the cost side of this. idea with patience and see their bills. a great proportion of their care is being given to them. it is being shifted to them through deductibles. it has really been a disaster. as an objective observer, i feel really bad for patients. i think it has harmed the patient-dr. relationship. i feel like something needs to be changed. host: diane is a nurse in ellicott city, maryland. good morning. caller: thank you for taking my call. i have been a nurse for about 20 years. just think there is a lot of benefit to the affordable care act. i think people forget what health care was like before and and how we were disseminating against people's medical conditions. people were going bankrupt because they cannot afford health care. i think that has eliminated some of those circumstances. there were a lot of people that were draining the system that were very ill that did not have health care that would just go to the emergency room for their health care. that is helping to eliminate that as well. overall, one of the callers had mentioned that we need to focus on preventative health care. before will correct it had the public health prevention fund that put a lot of money into prevention. that was one of the first things that was cut. lack of education and lack of preventative services is really what is making our society very ill. that we needg is to really figure out how to not have to many cooks in the pot. so many people are making big profits off of health care. that is our problem. host: republicans in congress, as donald trump looks ahead in jra, they promised -- january, they promised repeal in the first 100 days if not the first week. what should be kept in this process? should it be a complete repeal of every part of the aca? are there things that you think as a nurse should be kept in? caller: definitely i think we should keep the medicaid expansion. i am a school nurse now. one of my schools is a title i school. i see so many families in a fitting from that. i think people just don't have touch with reality that are making decisions in congress. mental health, that definitely needs to be addressed. that is one of our big issues as well. we should think more of refining versus for peeling and replacing. i think it is all about the verbiage. in general are not fond of the affordable care act all it brings. host: thank you. tim is here in d.c., a medical professional. caller: one of the things the affordable care act was supposed to do was keep patients from using 911 and the emergency room. one thing it seems to me is that this has suddenly increased and the aca has done nothing from my perspective to reduce the number of people wanting to go to the emergency room. i was wondering what is the incentive for people to go to a primary care physician as opposed to the emergency room and calling 911? because the vast majority of patients don't need emergency room. host: what do you do in the medical field? caller: i am a paramedic firefighter. host: compare your life as a 2009 and twon thousand 10 to what you are seeing today. 2010 to what you're seeing today. caller: there has been an increase since the 1980's. nothing has been done to quell that that was supposed to be done with the aca. there has been a steady increase in the public on reliance on 911 and the emergency room. host: we will talk about that issue. a couple of callers brought that up this morning. just a few tweets on this topic. one says, "the affordable care act did not make care affordable. it made cap mandatory." "aca is the largest give way to insurance companies ever." get thet it be nice to government out of medical care, then we could have c-spanwj go back to monday politics. " that will do it for this section. we will cover health care. we will talk about what health care might look like under president-elect trump and a republican congress. we will look at the issues of medicare and medicaid with two former administrators of the cmf . byst, january attempts republicans to repeal the affordable care act. tom price has been selected as the next health and human services secretary. here is a bit of what he had to say about the legislation they were sending to the president at the time. [video clip] >> this is a big day. for the first time since the law has been enacted, congress is one vote away from sending a broad repeal of obamacare to the president does. -- desk. it will aid the foundation for how congress can begin to roll back the disastrous policies that are destroying the sacred dr.-patient relationship. this is critical to our larger care fromrid health bureaucratic dictate. putting patients and families and doctors in charge of health care decisions. this reveals the most corrosive components of obamacare, illuminating almost $1 trillion in obamacare taxes and eliminates the employer mandate penalty. under obamacare millions of americans have been added to medicare system that fails to provide its patients with access to providers. we will and that. statesng medicaid so have greater possibility to care for those in need is the answer. repeals the premium subsidies and tax credits that have failed to control and have increased health coverage costs. it has made health care coverage less affordable and less accessible from millions of americans. this would allow for a new positive solution that would make the purchase of health insurance financially feasible for all americans and give individuals and families the power to choose the type of coverage they want for themselves, not that washington forces them to buy. it also calls federal funding for abortion providers. it increases the funding for community health care centers to direct more resources to women's direct care. estimates this will reduce the deficit by $500 billion over the next decade. the entire reconciliation would not have been possible had the house and senate not first agreed to a budget resolution conference agreement. the budget gave congress the authority to pursue the reconciliation process and the opportunity for this repeal of obamacare on the president's desk. the people are less interested in process and procedure. they want results. they want to know who is working to provide relief to the biggest challenges facing individuals and job creators today. no matter how you slice it, obamacare is harming the american people. premiums and deductibles are going ouup. millions of americans have been kicked off the coverage they had. that is the opposite direction we need to be going. the american people know it. we want a health care system that is affordable and responsive to their individual needs. full of choices and innovative treatment options. that is not too much to ask. , but only if we pursue patient centered solutions. announcer: "washington journal" continues. a monday morning roundtable, we are joined by stephanie armour of "the wall street journal," amy goldstein --the "wall street "washington post. " to january, on the repeal side can you explain what republicans mean. is this a complete repeal? are there components that they want to save? guest: that is a good question. part of the answer is we do not quite know yet. for six years since this law has been passed, republicans have been saying they want to get rid of it. in the house they passed more than 60 bills to do so knowing that they never had a chance. now with the election of donald trump, they will be able to do it. there is a lot of debate going on. that there ares some things that can be done quickly. those are the parts of law that can be undone with the budget agreement. for instance, the subsidies many people get him be undone. the mandate that people have insurance can be undone. the penalty for the law for people who do not have insurance can be undone. some of the structural things like the markets the aca created will be harder to do through the budget process. host: that is the reconciliation process? caller: exactly. the reason that is important is because the reconciliation process requires only that the votes in the senate to pass the bill. there are 52 republicans in the incoming senate. host: headline from last week saying that republicans say the repeal will begin in january. how long is that process going to take? all these things amy goldstein just talked about, is that weeks or months or years? guest: that depends who you are talking to on the hill. the plan from those i have spoken to is that they want to get this done quickly. they are expecting president-elect donald trump take executive action on his first day to knock down parts of the law. in the house and senate, they expect to go very quickly in the first 100 days to dismantle key pillars of the law. the real debate that is going on right now is in terms of a transition time or replacement. how quickly should that be done? some republicans say we will need two or three or even longer years to keep things largely as they are now while we hammer out a new plan. other republicans, especially the freedom caucus say let's repeal and replace at the same time were much more quickly. you are seeing some feuding going on. host: democrats have vowed to fight this process every step of the way. where might the democrats might be able to find victories or slow the process down? guest: the democrats are in an interesting position because they don't want to help the republicans. on the other hand they are eager not to have millions of americans stranded without health insurance. where the balance between that lies and how much cooperation they should provide is up in the air. host: millions and millions of americans without health insurance, there have been studies on this of what the repeal process would mean for the number of people who would lose health insurance or fall through the cracks. can you give us a sense of what the best estimates are? guest: urban institute and others have done studies that have indicated significant increase in the number of i'm sure. we are talking millions of people. a strongd to get number until we know exactly what the republicans want to put together. there is real debate over medicaid expansion. republicans in a number of medicaidve expanded and don't want to see it go away. we are talking between 12 and 15 million people who have gotten coverage for medicaid expansion. can we say because people will be uninsured? i don't think we can. guest: can i jump in? there was a bill that was passed last year that went to the white house. president obama vetoed it. the congressional budget office look at what the impact would have been on the number of insured people under that bill. it would have been about 22 million people losing coverage or 22 million more uninsured people at the middle of the next decade. tost: republicans i talked said they passed that knowing it would be voted. havereedom caucus members been talking about looking at subsidies. that is why it is nebulous to put a number on it at this point. host: you mentioned the urban institute report that democrats in congress were sending links to. , this was an estimate based on a partial repeal the reconciliation, which we talked about without a possible replacement plan. that is the study they looked into. they found the number of uninsured people would rise from 28.9 million to 58.7 million by 2019. 20 million would be newly uninsured, that would be from eliminating the premium tax credit and the individual mandate. those are some of the numbers. democrats have been talking about those a lot. the lines are open as we are having this discussion on the current state and future of the affordable care act. republicans (202) 748-8001. democrats (202) 748-8000. independents (202) 748-8002. we will start on our line for independents. bob is in massachusetts. good morning. caller: good morning. i would like someone to answer me at least one good question. we have over 300 million americans in the country. people are now covered under this obamacare, 10 million of them already had insurance. or $330,000trillion per head for 10 million people to get insurance. thank you. guest: most people in this country who have insurance still have insurance through employers. that part of the insurance system, while not perfect, and some people have found it getting more expensive, that is not the part of the insurance system that was really broken. the part that was broken was the people who are buying policies on their own. the individual market. that is what the aca marketplaces were designed to address. younding on the numbers use, between 10 million and 12 million people have gotten coverage that way. that is the number that tends to get thrown around. host: i will give you home or from louisiana. think that. caller: how are you this morning? appreciate you taking my call. i understand there was a republican gesture years ago. why did they fight it so hard and now they are going to come back to it? i am confused. i'm a daily listener. i don't understand. they have been up in washington too long. i think they get up there and make up their minds for us. it is their minds. i hope i'm making sense. host: thank you for your call. and for being a listener in louisiana. perhaps we could go to some of the early history of the affordable care act. guest: it is a good question. the affordable care act was passed in 2010. it was not a bipartisan bill ultimately. republicans were not very supportive of the affordable care act. they have been opposed to the law since its passage. you are now seeing the situation because of the election that there is an opportunity and they see a mandate for them to knock down and repeal this law that they have seen as leading to higher premiums and fewer insurers participating and requirements for coverage, all of which they say is hurting america. now they see this opportunity. the problem is everywhere they look there are potential landmines. one staffer said we have to be careful what we wish for because now there is a landmine everywhere. it is a tricky process. they want to get some bipartisan support from democrats. host: perhaps you can fill us in. this comes up from time to time with viewers, this idea that the affordable care act had its genesis in massachusetts under mitt romney as governor. that is exactly right. there is a little irony in how hard republicans have been fighting this law. some of the ideas, the insurance exchanges, came out of republican and conservative thinking from the heritage edition. in massachusetts, 2006 that pays -- that state passed a law under republican mitt romney as governor. host: mike is in cleveland, ohio, a democrat. caller: thanks for taking my call. noticedthing that i while i watched it on the news gone from the house to the it was rewritten so that the insurance companies one out.-- won the one key issue that affects a lot of families is the fact that previous conditions will be covered, so if you have a cancer victim in your family, the insurance will cover them for what they need. one of the issues that i don't agree with his the fact that unions are being taxed to support health care. if they do rewrite this law, i would like them to repeal the union taxation. thank you. host: do you want to pick up on any of that? guest: it's interesting that the union tax was obviously an issue for those who initially supported the health law to have some opposition toward it. the issue that you brought up that i think is especially important is the pre-existing condition upon it. -- component. what will happen with this, we really don't know at this point. continuing and a number of republicans on the hill support this. how you do this without some of the other requirements of the law like requiring others to have health insurance. how do you pay for that? there is some dialogue on the hill now where they would set up a system where everyone would have coverage, but those who would let it lapse go into a high risk pool. has been used before in states. unfortunately it has not been effective. people had to wait for a long time. it has not been adequately funded. they're going to do this is really the $10 million question. host: health insurers seek clarity. a quick repeal of the 2010 overhaul law will stymie their market. can you talk us through what health insurers are saying and fear as they look ahead to what may happen in january? guest: i think health insurers are very concerned at this point. they had not seen this coming and had not planned for it. but many people don't understand about health insurers is that they have to decide early like in the spring of next year whether they are going to participate in the health insurance exchanges for 2018. they'll have the luxury of waiting to see what the republicans are going to come up with. they have to make the decisions now. the fear is that the current system of the affordable care act may have problems. they were losing money and a number of them were leaving the exchanges. they want to see fixes to what is currently there, but at the same time, if those fixes don't go through, they may not want to participate in 2018. the have a lot of requests that they want to see done and there's lobbying on the hill to get some of these changes to go through. republicans are in a position where if they agree to some of them, they did not want to seem as if they are giving a bailout to insurers. host: good morning. caller: great discussion about this affordable care act. i'm an independent businessperson and i remember back 25 years ago when i first started having insurance. it was $180 a month back then. employed by corporation who had their insurance pay for them. up andear, it kept going it would be like $210, $260, $300 this was like 25 years ago. now people are complaining about paying $400 a month. back then, businesspeople were paying as much as they are paying now. back then, i couldn't afford it anymore. i was unable to have insurance. i did not have insurance for 15 years until the affordable care act. medicaid, a managed which works marvelously here in new york from my situation. i know there are valid concerns about the act not addressing some issues. they might want to talk with medical personnel and get their input because they have a lot of good insights on how it can be improved. host: one of those medical personnel who will have a lot input is congressman tom price. can we talk about where he is right now on this law and what he's telling donald trump right now? guest: we don't know exactly what he's telling the president-elect, but what we do know is that in choosing dr. price as the next secretary of health and human services department, which obviously overseas a lot of things, including the execution of the affordable care act and perhaps the dismantling of the affordable care act. the president-elect has chosen one of the members of the house of representatives who has been one of the strongest proponents for the repeal. this is not someone who is subtle about his thoughts on the law. inhas been very influential what has been a consensus house republican plan called a better way that has ideas for how to deconstruct the law. atis putting into position hhs someone who has been front and center in the repeal effort over many years. host: stephanie armour, on what to go through donald trump's health care plan. he has talked about what he wants to see included. ing theand th affordable care act, modifying the existing law that inhibit sale of health insurance across state lines, allowing individuals to fully deduct health insurance premium payments from tax returns, allow individuals to use health saving accounts, block grant medicaid to states, remove the barriers to entry into the free market for drug providers -- some of the things that he is put on his website. let's talk about insurers selling insurance across state lines and why that is seen as such a big six by donald trump. guest: that's a good question. been one ofis has the main things he talked about when campaigning -- removing the lines around the states. host: what does that mean? guest: currently insurers can sell across state lines. there's nothing that prohibits them from doing so. there are under the affordable care act compacts that can be set up across states and their statements. what's different is that if you are an insurer and you are based in new york and you sell a plan in california, you have to abide by the rules of california and what they require you and your insurance policies to have. they may say, for example, you have to cover these benefits or you have to deal with consumer issues under california. what president-elect trump would do instead is say that this insurance company can sell a policy in california or they can sell it in arizona and it needs to abide by the regulations where it is based or license, so for example, new york. they can sell that policy anywhere, but they can be located in a state with very little regulation. that would lead to more "skinny plans" with benefits. host: would that lead to a lot of states with the least amount of regulation? guest: it's like with credit cards. everyone went to delaware. and shares would be most likely to locate or lessons themselves in states that have scant regulation. host: new york is one of those states? guest: no, new york has lots of regulations. i just use it as an example. host: what state has fewer regulations? guest: i do not know what state is the most lax. there are insurance commissioners in each state. i think there is a concern that there is a free-for-all that states would raise themselves to see how far they can relax a galatians to get -- regulations to get business. host: a so-called race to the bottom. taking your questions and comments about the state and the future of the affordable care act. stephanie armour with "the wall amyet journal" and goldstein with "the washington post." alayna, good morning. caller: i have to points to mention. the first point is how the st. jude's shriners hospital for children -- how do they manage? they manage on charity. i think that's a marvelous example and perhaps health insurance providers should go see how they are doing it. because they're doing something right. they have survived a lot of this debacle. my second point is this. there are a lot of mothers who can do the shopping at costco. i worked there. my husband, he is our health care provider. we have always gotten our health insurance through him. like a lot of other mothers in our community, there was a lot of said this at first -- sadness and frustration when obama gave us obamacare. , we lost $1000 in our paychecks per month, plus the employer was provided another $1000 for his end of our insurance benefits. so what do we get from it? well, we used to be able to go and pay ator's office co-pay for $35 a visit. now, there is no co-pay. deductible,o meet a a $6,000 deductible for a family of four. that was not very pleasant. so after we pay roughly $2000 a month, i have to come up with $150 to $300 for the office visit. am i going to the doctor? no, and i think that was the sneaky trick in the obamacare health care. we need to shave people off the health system. first of all, no one is going to go to the doctor because it hurts. those tests are hurting. unless you are running a fever and you have got a sore throat, you really don't go to the doctor. but if you have a fever and you are hurting, you go to the doctor. host: thank you for sharing your family situation. amy goldstein, what are you hearing there specifically about what cc as an effort to get people out of the system, to price people out of going to the doctor? through'm not sure that her description of whether she was on a marketplace for getting private coverage. either way, there have been over the last number of years a trend toward having people having to mak paid for their out of plan costs. some of that is under the law, but some of that is being in the private insurance marketplace. i'm not sure which descriptor situation, but she does make a point that many people on the exchanges or off the exchanges are experiencing -- that they have to pay much more upfront. that is a real phenomenon. people, as we were saying a little while ago, maybe 11 million people getting coverage from the marketplaces are increasingly finding insurers are losing money in that part of the business and they are charging more. understandably people don't like it. host: how much do you think the affordable care act gets blamed fairly or unfairly for increases that have been happening for years in health care just in general? guest: that's a really good point in your question. people conflate what the law itself is doing with their own experiences, which are unrelated to the law. there may be experiences parallel, but they are not caused by the law all the time . host: eric is a democrat, good morning. caller: when i was in the evening, health care plans have gone up. host: you are on. go ahead. caller: why are republicans adamant about repealing this law? this law is about helping each individual in the united states. it's not that each state has its own individual rules for how they go about implicating the law. i think their truck to kill this man's legacy. you can tweak it and work on it and get better, but you just cannot go out there and spend billions of dollars to repeal a law that isn't going nowhere. what trump is doing is promising the people that ain't going to happen. it's not going to happen. this is my questions -- why is it so important that republicans repeal this law? host: stephanie armour? guest: there was a survey done shortly after election and it showed that -- i can't remember the exact number, but it was between 40% and 50% of people who voted for trump wanted to see the log repealed or changed. i think the republicans i spoke to on the hill really feel like they have a mandate to knock down the law. they feel like the voters and their constituents are unhappy with the law and want to see the law changed and replaced with something else. seeing now with the republican victories in the election is that they feel like there's an opportunity but also a need for them to follow through on the promises that they made. that is partly why there is a push from some republicans to do this quickly. they feel the voters were not happy with the law and want to see the law changed. they said, there are studies that show strong support for the law from other voters. there is a great divide going on over the flaw. -- over this law. that's why it has been polarizing since its passage. host: i have that survey. repeal the lawto entirely or scale back what the law does. 30% once to expand what the law ants to move w forward with implementing the law as is. after whatever happens in the next year, does this become trump care? are republicans now the ones who will be blamed or get the credit for whatever comes from this? guest: we don't know what it will be called. we don't know how it will be yet. this is very much in the republicans hands at this point. that very clear to them whatever happens with this law will impact them and will be seen largely as being on their shoulders, whether it fails or succeeds. that is one of the concerns for the midterms. vulnerable are not should voters not be happy because they are only defending eight seats in the senate. i think they are very cognizant of the need to not have this completely caused tumbles and problems in the market and that is why they are debating a transition period. host: let's go to robert in greenwich, connecticut. caller: good morning. how are you? mi on? host:. yes. caller: oh good. i find it ironic that a doctor is put in charge of repealing this. i seem to recall the hippocratic oath is first do no harm. that's what doctors have to swear an oath to when they become doctors. it occurred to me that putting 20 million people out of the health care system might cause them a little stress and harm. i was just wondering if he had any way of reconciling that. host: amy goldstein? guest: in the house of representatives, there is a doctor and physician caucus. tom price is part of that group. among republicans, the fact that these folks have medical degrees, i think gives them a little bit of stature further policy beliefs. physicians can disagree about what is best for the health care system, but within the republican caucus, the fact that he is a doctor makes his colleagues think he has some --ght and legitimat cy.itimatv host: what makes it different between a doctor? guest: recently has been governors who, to the position. theia burwell came from head of the office of management and budget. it's often people with executive or managerial experience is accurate. this is a very big agency. we have been talking about the aca, but the agencies and the department also oversees the centers for disease control, the drug administration, so it's a big place. host: stephanie armour, who is froverma? guest: she is working under dr. price. she is a strong supporter from republicans. she brought a lot of changes to medicaid that i think republicans feel is on the right trajectory of what they would like to see happen with medicaid. into a blockmoving grant program is one thing that they would really like to see as well as some of the other things that she supported the given states more control over medicaid. for her, at hhs, my guess is that you are going to see a lot more waivers in states that change the way medicaid functions or operates. for example, there may be more work requirements or people are asked to pay a small premium in order to maintain coverage. host: the office that she would take over is the centers for medicare and medicaid. last month, the current acting administrator of cms appeared at the american academy for actuaries. viewers can see his entire speech on c-span.org. he talked a little bit about the sustainability of the marketplace. it's a topic we have been talking about this morning. here's a bit from that appearance. [video clip] . >> the first thing we have to do is step back and see that we are ensuring people with no questions asked without regards to the health. we are asking companies to do that without any data and very little understanding of that cost. what has happened is that in the first couple of years, many folks -- no necessarily real fault of their own -- are priced too low. i think some expanded too fast. that you are seeing some .olks adjust and certainly many markets, the prices moving higher than they have been before. in the third year currently in 2016, overall premiums in the marketplace are about 18% below the original estimates. we have been tracking below. i think we will see greater increases this coming year and i think we will be more balanced and spot on to where we should be. some of it is to make up, but it's also a very new business for companies. i think what's most encouraging is to see that there are a large number of companies who really understand that it's a new business and are not treating it like the old individual market or the medicare market or some other market. they're really adapting product designs, network designs, and the best companies are expanding it as they view this new retail world. there are things that we are doing. as we look at the data to make sure elements of things that we are driving costs unnecessarily, like third-party payments, are managed better, and i think we have taken some steps and we can obviously continue to take those. thatly i would say probably the open question remains the same that occurred before the aca, which is that there are some markets in this country where there is not enough competition. particularly rural parts of this country. that has always been the case. i think this is getting more of the aca exposed to that reality. i think there is a real question. we have selected a model that is private sector driven. the real question is whether or not we need something that feels more like medicare. i think that is part of the debate and we will have to look at particularly those rural communities. host: if our viewers want to see that entire speech, go to c-span.org. armour, he's reading what he seeing in the marketplace and the data. it's different from what the republicans are reading and seeing in the data. guest: it's like the blind men and the elephant. it's there, but everyone see something different. he was definitely talking about ways that the law has worked, ways that people got in to make health care more affordable. he is also talking about changes being made to help make a lot more sustainable. republicans see the opposite. they see premium increases in the double digits. they see insurers, such as united, who say they are losing money and leaving the exchanges. no matter how you look at it, the one thing that is very true is that the affordable care act as it currently was working was having troubles and challenges. the democrats answer to that to some extent was let's fix it and add public option. that's a government option that would be an insurance option that people can pick from. that's not going to happen. instead we are going to go down a different path with what the republican see. they really want to point out that there are problems with the law already. you see a lot of defense of the law right now from democrats. host: we have 20 minutes left to take your questions about what this might look like and what the current state of the affordable care act is. george is a republican. go ahead. think when mitt romney did his act that it was affordable. once theened was government was going to pay for it, the banks increased the cost. and people lost out. -- the the republicans laws that they were passing, they made it harder on .ittsburgh to maintain the cost if you look at the cost rates, they have doubled. the banks are hitting a double-digit thing. they are getting paid by the government and getting repaid by individuals. the poorer you get, the more cost to actually do it. the banks need to get out of health care. because if they continue in it, we are going to create a debt bubble like we did in the housing industry. host: amy goldstein, can you pick up on that -- the banks involvement in this process? guest: i'm not sure i understand his point about the banks. let me point out an observation. itmassachusetts, even though was a precursor to what became federal law, massachusetts actually had a little bit easier job. historically had a very low rate of insurance. the number of additional people who had to get covered was not as great as it was in all parts the country. the second point is that these exchanges, which as you have been saying, have had the things and bad things about them. they have really had a hard mission because they happen picking up people, who in many cases had not been without health insurance or with health insurance, who had neglected medical problems. those people have used a lot of health care more than the insurers were expecting. they were expensive to cover. there has been some built-in problems with the way things played out nationally that were not quite as true in massachusetts. host: let's head to their own beach, florida. good morning. caller: thank you for taking my call. i believe in universal health pension foro everybody. what we should have is progressive taxes according to the income. taxes go up or down according to inflation. it's like the euro. we should have universal health care and universal tension. other than that, i think it's the best way to do it. if the taxes go up or down, that's part of the implementation. host: these topics come up when we have discussions on health care in the united states -- system and to our other countries. could we model our system on one that works better? is there one or two that the donald trump administration is looking at or any ways to better improve the american health care system? guest: but the republicans i talked to on the hill, there pointed to health care and other countries as what we do not what to do. it is the opposite. they see canada, for example, or some of the government provided health care as just a way they do not want to go. their point is that they want less federal and involvement in health care. they are opposed to the public option earlier voted by democrats. going forward that is unlikely to be something on the agenda and will continue to be something more along the lines of what republican see as being more beneficial, which is much more a free market approach . host: let's go to alabama. good morning. caller: good morning. i was wondering what was going to happen to these lower income people caught between working service jobs that are only available now since insurance was attached to mainly manufacturing jobs and everything else. those people are barely making it from week to week. it's not going to do them any good to have a health care savings fund. if they get a voucher, they're probably not going to be able to afford it. i was interest for a long time and i got injured. my husband was on disability could h. he was covered by medicare. i was injured severely and i had no shirts. i cannot afford $1500 to pay out. i listen to people call in. there are people who can never go to a doctor because of expenses and they will be lost in all this. host: i thought you are done. amy goldstein, pick up on that. guest: it's something that's really fundamental. one of the things that the aca has done is that for the first time given working-class people and people a little bit into the middle class subsidies. help byernment money to private health insurance. about 85% of the people who have insurance policies through these marketplaces are getting this federal money. now subsidies are not something b the incoming administration likes at all. there's another issue which is that since the late 1990's there has been a children's health insurance program. that is specifically for the children of working class people. that law is going to come up for renewal fairly soon. it is really unclear what's going to happen with it. host: what is a health savings account? guest: a health savings account is something that exists now. it has been a longtime republican favorite and health policy. it enables people to set aside money that they can withdraw tax-free. they can withdraw it without any penalties and use it for medical purposes. people of all incomes have it. there are some research literatures that show higher income people are better able to save money that way who have been benefiting the most from these health savings accounts. president trump says he wants to expand them. he is not that specific on how he wants to do so, but something he talked about repeatedly during his campaign. host: what is a way to expand that? guest: better tax rates. this is hypothetical since we really do not know what he will do. better tax rates. there are limits on how much money you can set aside, so those limits could be expanded or gone. it's a little unclear, but it's something that he really likes. host: let's go to wayne and little town, pennsylvania. good morning. caller: how are you doing this morning? host: doing well. should look, this here be eliminated. market -- it's bogus. it is all for the rich. pharmacies can charge what they want. people have got to realize. special interest is being handled by some of them. they are going by the special interests, all that money coming in from pharmaceuticals, -- i and got time to explain it all. john, just a minute. if all thing is industrial countries like bernie sanders said can afford to do it -- i know people in canada. this stuff is ridiculous. people going in debt and losing their homes. people care and love each other. help. no, but everyone's going to go in debt or lose everything they've got to keep the pharmaceuticals and all the others tie money. host: thanks for the call from pennsylvania. stephanie armour, can we remind viewers of bernie sanders and this health care issue and what he had to say about it on the campaign trail? isst: bernie sanders was and very much in support of a more expansive public option. basically government insurance. basically government insurance that anyone could get it would be on the market and available . while it's important to remember what bernie sanders wanted and many supporters rallied around, i still think we need to have to focus on reality and that that is very unlikely to be happening at this point and this point going forward. i do think the point that he was raising is important about all the various players that are going to be involved in whatever is drafted going forward. the pharmaceutical industry, the health insurance industry, and that's going to be a real challenge for republicans. how do they keep these various aspects happy? you cannot get something passed it seems to me without the support of the pharmaceutical industry, as you saw in 2010 with the affordable care act. just about 10 minutes left if you have a question or comment. .epublicans --(202) 748-8001 democrats --(202) 748-8000. --(202) 748-8002. jeremy, good morning to you. caller: i have a question about competing across state lines. martha prices with hospital -- part prices with hospital networks negotiated based on geography? i'm wondering how that works. when they have to have a certain number of people to negotiate a lower price with the hospitals? i'm wondering how that would work. guest: there are a couple different issues at the that the caller raises. is that would all work insurers, as you are saying a little while ago, are able to bypass state regulations. what the geographic basis would be for setting prices is really not know opal now. -- knowable now. there are wide variations in hospital prices for the same services. that has been true for a long time, whether it's anything republicans might come along with to address that, we just don't know. guest: another good point that he raises is that is the biggest stumbling block to selling insurance across state lines. the reason it has not taken off is that it's hard for new insurers to come in and build up those networks. they are at a competitive disadvantage. host: we have a headline from "u.s. news & world report." obamacare repeal efforts -- mental health care would undo recent progress made in the critical areas. mental health care was one part of the legislation passed last week and president obama is set to sign with the toy for century cures act. wisest being seen as a flashpoint -- why is this being seen as a flashpoint? guest: there has been a years long drive toward mental health parity, which is good coverage for mental health services or physical medical services. this is one of those ways in allh the aca incorporates kinds of goals that people had with the health care system. -- this is ared regulatory thing and not a law thing. they required health and human services to oversee a definition of what standard benefits would be included in people's insurance. not just on the exchange, but all caps a private insurance. you quality from at the health services was part of that definition. people who care a lot about this issue now feel that this could be at risk. host: could the legislation passed last week once it is signed on tuesday -- could that be changed or pulled back with whatever happens with the repeal of the affordable care act? guest: the cures act definitely focuses on addiction, treatment, and some mental health. that is very separate from the insurance plans must provide mental health coverage as one of their "essential or mandatory benefits." i definitely think republicans are interested in scaling back the mandatory benefit requirements. they want less regulation of insurers. i think the concerns about eroding the protections for mental health coverage are legitimate concerns that people have. guest: if i can expand on that, there are many groups of people who care about different aspects of health coverage. among them are women who care about reproductive rights. there's a whole set of women's health benefits that are now included under the standard or essential health benefits. some of that includes coverage for things like contraception, which the incoming vice president is not a fan of. there are lots of moving parts to this law that are up in the air now. host: we only have a few minutes left. several callers are waiting to ask questions. florida. an good morning. caller: what i would like to ask is when the affordable care came , the businesses had to give less hours so they did not give employees the health care. -- whyt they give people can't they give people more hours and the bosses give health care back? i know a lot of people that lost their health care through their place of employment. why did that stop? why don't they give people back their hours and let the employers pay them their health care back like when i was working my regular hours? i got health care through my place. host: stephanie armour, can you explain a little bit about the process she is talking about? guest: she is talking about health insurance provided by , which has been required under the affordable care act that it be provided for employees who work a certain number of hours per week. the things that she mentioned is this misconception out there that the affordable care act has led to a large number of employers dropping the health care coverage they provide for their employees. in fact, what was really quite surprising is that has not happened. it is one reason that the number of individuals who have gotten coverage on the health law exchanges is lower than initially projected because employers have not dropped that coverage. host: we will try to get mary in ohio. go ahead. caller: my 95-year-old mother recently broke her hip and is in rehab. i think every politician should have to spend two weeks in a facility like this and then maybe they would come up with a solution to the health care problem. talk about the unborn being vulnerable. when you look around in these nursing homes, you see who the truly vulnerable people are. that is my comment. thank you. ont: mary is our last caller the segment of "washington journal." i want to thank both stephanie armour and amy goldstein, both health policy reporters. you can see their work online at their respective websites. i hope you can join us again. up next, we are going to be talking about the future of specifically medicare and medicaid. eck scully and bruce vlad will be our guests in the next segment. more from the current cms administrator. he spoke last month. in this segment, he talked about how the affordable care act can be improved going forward. [video clip] do next?t we do need to cover more people. we have just the gun. the most obvious way to do this is expand medicare everywhere. people, state budgets, health care finances will all immediately improve around the country. we know this. exchangesums on the declined by 7% in states where medicaid has been expended. second, we need to reach millions of people this open enrollment period who are chronically uninsured, most of whom do not realize coverage is affordable now thanks to the tax credits available to them. open and roll meant began tuesday -- enrollment began tuesday and one thing is clear -- the demand for coverage is real. hundreds of thousands of people apply for coverage of the very first day. third, we are going to need to teach people how to adapt to live in this new normal. it doesn't happen automatically . we are beginning the process in communities across america of reconnecting consumers to the health care system. all of us though are going to need to adapt to this new normal. for the consumer used to making trips to the er when things get too bad to deal with, it's learning about all the preventive and primary care resources available. for health plans, it's adapting the past business model designed around underwriting to one designed around care and network management. for the hospital, is learning how to make money by emptying bed and not killing them. -- m dean beds and not filling them. to continue the new normal, we cannot go into the new world without making adjustments. fourth, find the places where tweaks and adjustments will help the aca work better. we are in the early stages of a very new set of rules and we are just now beginning to see the data on how care patterns, costs, and opportunities are emerging. areries of policy decisions typically going to be necessary to improve the law and make it work the way we want it to. things like risk adjustment, state-based waivers, the impact of third-party provider payments , i would ask you to put politics aside. there would come a time for adjustments, whether at the state or federal level, and all the things should be considered in order to get them right. i think our jobs are to make sure we look at what is happening so we can get it right. announcer: "washington journal" continues. host: for our second round table of the day, we are joined by tom ecklly in d.c. and bruce vlad in new york. the centeras head of of medicare and medicaid services during their spec of years in the federal government. they join us now for a discussion on the future of medicare and medicaid. let's start with bruce to get us all on the same page. can you remind us about the differences between medicare and medicaid and the basic services that each provide? isst: very quickly, medicare a traditional social insurance program that grew out of social security and is part of the social security act. it is financed in part by payroll taxes that everyone .ontributed is it is also financed by general tax revenue and premiums paid by beneficiaries. essentially everyone over the age of 65 in the united states with any work history or who has a spouse with anyone with work history is eligible for medicare. in addition, medicare covers about 8 million people who are receiving social security disability income and is below the age of 65. they have been determined to be permanently disabled and are receiving disability insurance through the social security system. the medicare is benefit package by and large is unfortunately a little bit originally modeled on the standard blue cross blue shield plan that was in effect in most of the united states in the early 1960's when the legislation was written. there have been some significant additions over time. tom is probably responsible for one of the most significant, which is the addition of part d, which covers prescription drugs. it is a classic health insurance program in the sense that it doesn't cover long-term care. it doesn't cover most services like eyeglasses. hospital care, physician services, related services, it's quite apprehensive. medicaid, which was enacted in the same time as medicare, is a joint federal and state program , which historically covered folks who are eligible for other .orms of cash assistance low income mothers and children, the disabled and blind, and the low income. it has expanded over the years. states,amacare, in 31 it expanded even more broadly. and now covers in the states that have expanded medicaid essentially everyone who is legally in the united states and has been for five years or more up to 138% of the federal poverty level. in a non-expansion states, the coverage is much more limited . medicaid is a comprehensive benefit package. hopkins folks at johns were asked to do a study of what the best benefit package was available for severely disabled people, they looked at all the private plans in the market and came back with a report saying medicaid is now the largest insurer of the united states. more than 60 million beneficiaries on any given day. birth and the the united states are paid by medicaid. traditionally by law a relatively stingy payor for services. most beneficiaries get their services through managed care plans, but the rates are based payments for hospitals, physicians, drugs, other services that historically by law had to be the lowest prices. part, the federal government pays a variable share of the cost of the program. although it is administered by the state, it pays at least 50% of the cost in more prosperous oftes and 95% of the moment the cost for the so-called expansion populations. available as a response of obamacare. formuladetermined by a based on state per capita incomes. , itdministered by the state is subject to federal rules and supervision. host: the cost of medicare and medicaid both to the end-user into the government certainly a topic that we want to talk about in this 45 minutes or 50 men discussion that we are having here. medicare and medicaid recipients, you can call in on a (202)al line for you -- 748-8000. all other viewers --(202) 748-8001. i want to hear your questions and comments. comps: as with -- tom scully is with us in bc. bruce talked about the expansion under the affordable care act. how did aca affect medicare? that much, by the way could that was a hell of a summary. you can tell he is a professor. for people up to 40% of poverty, they can get into the private health plan and they get subsidies for that to expand medicaid. the impact on medicare, there were modest impacts, but it really was not mok focused on medicare. medicaid,impacting on can you talk a little bit about the cost of doing that? what was the bottom line for that expansion? guest: the bottom line will get complicated especially with the states with the option to expand. states, forsouthern example, did not cover single men or women with kids. family,re a low income and i think most of the northern states did. he had a huge increase in the population. and the health care business, there are in albuquerque and the uninsured went from trouble we 18% to 8%. 8%.ent from probably 18% to it took the uninsured rate down in states that did it, but not all states did it. president trump will either freeze it or he may turn into a per capita cap. some states basically took 100% of the money and did what they want like mass expansions. others did not. where do you freeze it? you will find it interesting when most of the southern states did not take the money. they're probably not going to be excited about freezing it exactly where it is now. the northern or western states that took the money, we're going to lock them in a $10,000 ahead it's going to be huge formula fights with most massive local issues around medicare expansion. have you basically change the structure? host: i want you to weigh in on this as well. what happens with this medicaid expansion under present trump and republican congress? guest: i have no idea. i think tom described some of the political problems pretty accurately. fight inhrough this so-calledith the contract with america congress p th, ,. they passed a block grant and the president vetoed it. there was a years worth of negotiation between the administration and the national governors association to come up with a formula or a per capita cap that would protect beneficiaries at the same time gave the states some of the increased flexibility. they said they wanted those negotiations and they essentially went nowhere. it's a very difficult political problem. as we say what was in the health care finance and menstruation, --icaid isn't rocket science finance and ministration, medicaid isn't rocket science. moving those kinds of dollars around when different states have different stakes and perspectives, given the design of the congress is a pretty complicated undertaking. host: go ahead. guest: what you will find is that a lot of republican and democrats fight, but want to get into the money, it's much more often that you get into the weeds of the medicaid state versus state and not republican versus democrat. program, the rules are so byzantine. i'll think there's anyone in the unite states he can explain the funding to you. there are a lot of problems with the light which. -- with the language. if you like getting it done, it's very complicated. host: we are going to get into some of those issues over the course of the next 45 minutes. tom scully is a former administrator for the centers of medicare and medicaid services from 2001-2004. k is the former administrator of what was then known as the health care administration. we will take your comments. we will start with jimmy on our line for medicaid recipients, calling in from pennsylvania. you are a first. go for it. caller: since obamacare came in, you have a lot of people going on disability and their collective medicaid could president -- and they are collecting medicaid. present obama took money out of medicaid. how long is it going to last? guest: there's about 8 million people on medicare. if you are disabled, you go on medicare. it would cover you if you are 65 or older. one of my great concerns over the last years and i know bruce will disagree is that i think the disability rules in the last 10 years have gone to high. i think a lot of the areas to the disability qualifications have been lucent. medicare and medicaid should cover people who are disabled. the floodgates have opened. in the last 10 years, you have a lot of people coming to medicare that my opinion should be on social security disability. i think the collar has a point. disability has been a little out of control. host: do you agree? guest: no. thats followed a pattern during recessions in every that therezed nation is some kind of disability insurance for working people. when the labor market gets very weak and unemployment increases, the willingness of employers to hire people with some really physical or psychiatric impairment does ministers because -- diminishes because they can find people without such limitations eager to work with them at lower wages. when the economy gets better over time, the expense has been in the united states and every other country with disability insurance that the number of people becoming newly eligible for disability begins to fall again. i think the great growth we have seen in this and the last decade attracts what happens in the labor market very closely, starting with the great recession of 2008. if the increased enrollment were to continue over the next several years while the labor market has gotten substantially healthier, that i would begin to worry about it. but we have seen so far is just consistent with historical in employment rates and the availability of jobs for people who are less than completely physically fit. the tom scully, caller was concerned about money being taken out of medicare for other purposes. i just want you to explain when we say the medicare trust fund and the concern about using that money or dipping into that fund. fund: the medicare trust is known as the medicare part a trust fund, which is for hospital. andyone pays that and taxes you see that on your payroll stub. some of your income and your employer does and that funds hospital part a. funded 45% by the federal treasury directly. the bolt is roughly $25 month . i think you can talk about taking money out of the trust fund. thus make the two trust funds. i think it's hard to find what has happened. n christmas eve behind closed doors, about 3:00 in the morning, they shut out the republicans totally, wouldn't to anything that they proposed.e they wouldn't even hear of. now one comment i want to make on television d is one of the senators, i heard not about his is health care, this is about people.ing the that, it was gotten by fraud because a president lied. he said, if you like your doctor, keep your doctor. if you like your hospital, so on and so on. my husband lost his insurance and now we pay. it is just terrible the way it was gotten, it really is fraud. it was big deception and even that goober who was responsible for putting it together said he had a lie because of stupid people, they would not you know. want to take us back to politics of the passage of the affordable care act in guest: one thing we can say about the affordable care act, it's generated more rhetoric than any other piece of health legislation in the united states an it has generated in environment in which people can ake all sorts of claims and claim all sorts of things that aren't true or distort them or context.em out of i think that is litigating an old fight. think the fact of the matter is we've been living with want back to politics of the passage of the affordable care act obam care now operationally for three four years, there are substantially fewer americans than t health insurance there were before it, before the ate of increase and healthcare cost has been slower than it has historically been, although it pick up again. the health benefits are show through a variety of studies in terms of health for people who now have access to healthcare and economists have looked and out, upside down, to find negative effects on the market from obamacare, hether it's cutting back in hours for people who want to or reducing jobs, where reducing employment related insurance, none of those happened.pear to have is it perfect? not by any means. fixed? need to be absolutely. the fact is there are 20 million today who are better off than they would have been enacted and the costs born by just about everybody else in society have relatively modest. ost: raising his hand to jump in. uest: we disagree on lots, world trends and, you know, the healthcare politics has gotten ugly, the reality is, obama was do the right thing. overdid s correct, but it. the fundamental issue, who do you subsidize and how much? 10 to 15 years ago, the ated -- roughly 40% of population. what obama care did, took it to poverty, 15 million more people, 67% of the population. when you have a great insurance the population, that is a lot. had epublican view, they too many benefits for too many subsidized highly and mes kayed expansion was too big. got to the point where last six or eight years, republicans thought this was the worst thing in the world blowing up and democrats think it is perfect and we shouldn't touch it, the reality is somewhere in between. republicans will repeal it, i think, scale it back significantly. hey will not take 20 million and throw them off, but make the benefits less and fewer people up in the income stream and make cheaper, which is what they wanted to begin with six years ago, they were cut out, i think that is the caller's point. unfortunately for everybody, to be 100% partisan vote in both houses and turned into a nasty policy ar for six years, which is too bad. host: future of the affordable care act has been our topic. medicare and medicaid, specifically the of those programs. a special line for medicare and medicaid recipients. on 748-8000. others call 202-748-8001. john is on the line for -- may i make a semantic entirely t is not irrelevant. raditionally, we have used the word medicare beneficiary and now we use the word medicaid beneficiary. recipient is a term applied to people who receive welfare and fact, t working and in essentially all medicare beneficiaries paid into the system, contributed to it throughout their working lives that creasingly in states expanded medicaid, the majority f medicaid beneficiaries are people who are working and who are xes and/or elderly or disabled and worked or paid taxes before becoming or disabled. always had a has more connotation and eneficiaries deserve that, not stigma of implying they are getting welfare. beneficiary in youngstown, ohio. you are up. caller: thank you. this program ave on right now. i have an interesting situation and i'll ask my question. retired at 62, live on $965 a social security and just got my medicare in the mail and denied part b because vimedicaid. is, how do i have or 120 a ay the 105 month taken out of my social check and then second, ecause medicare has roughly 5% administrative costs, i'm wonder whying they don't just lower the age limit over 10-year span down o zero and have everybody on medicare? host: i'll let you start. take that question is hours. as far as your specific issue, assuming ly are 62, you are on disability because otherwise you wouldn't be medicare. general matter and i don't know specifics, depending on your income status, the medicaid will not pay medicare part b, but medicaid should cover other wrap-around benefits. partisan issue between democrats and know ares. republicans believe medicare is fixes rful program, it prices and inefficient because government is setting prices and running single-payer 75% ofent-run system for people on medicare, who are not on private health plans. people on medicare are on private health plans. service government program where the price is set and administered. most people on the republican side would say, look, worst thing to do is expand below 65, get a more competitive system. most medicaid is managed care. away from the government fixing prices and having ssential cms, bruce and i both worked at. set prices and get in private insurance. know bruce disagrees with that, we talked about it over the years. odds of next 10 years i think of the retirement age for going to 65 or fairly slim. most republicans will push it to push it up. host: mr. black, give you a chance. guest: the fact of the matter is works better than any other health insurance plan in the united states. cost, the est overhad highest proportion of professionals who participate the dwifrngz between in network out of network that is so critical in many private effectively ns doesn't exist in medicare where 7% of all physicians and essentially 100% of all ospitals participate in the medicare program. -- it doesn't have, which private health insurance plans are required to under the aca, cap on out of pocket expenditures and that has to be but unless have you those kind of catastrophic expenditures, your out of pocket cost on day-to-day basis are ower than they are now in typical private health insurance employers.ided by so historically before the care act, people who did not have full-time jobs ages of 62 and 65 were in a total no man's land in terms of healthcare. insurers wouldn't cover them and among the greatest beneficiaries of the affordable act have been people 65 who aren't yet eligible for medicaid and ouldn't historically afford or purchase at all private health insurance. one of the really interesting about repeal and what the going to be congress decides to do about vulnerable ally population because without a mechanism like the exchanges and subsidies for premium prices for povertyelow 400% of the level, people between 62 and 65 related have employer insurance have traditionally been totally locked out of of course rance and that is an age when people begin to be increasingly vulnerable to healthcare problems of one kind or the other. o that will be, i think, pivotal question in whatever the how ssor to obamacare is, does it address the needs of those people. i think expanding medicare to 62 for the very good economy, would be good for older would iaries and permanently solve the problem of what to do about health people who are no longer working, but not yet old enough for medicare. plenty of callers on the line for those with questions. back to e two and come the panel. middleton in west virginia, good morning. kwau caller: good morning, john. both of your commentators comment on this serious issue that i think, they had to do with medicare supplement insurance program that allows to do urance companies you with pre-existing conditions, they can deny you a had anything have done within six months or a year for a policy that they can deny you and turn you own because of your pre-existing conditions. it has been in the medicare law will work on ody that problem. i like both of them to comment it affected because me when i wanted to switch my insurance company to another one. me three different companies denied me because of conditions. to have a comment on this. host: we'll let them do that, let's hear from james in florida on the same line for the questions about medicare and medicaid. go ahead, james. caller: yes. to have a comment this. host: florida, zephyr hills, been disabled since '65 -- i'm 1998 and what medicaid program s a special called share of cost. the share of cost is figured on onthly basis through medicaid and share of cost is almost what your social security is each it is totallyeans impossible for you to meet your to a of cost and go doctor. plus, doctors are all pecialists, they put me on a catastrophic program. still not going to help me hatsoever because of the share f cost is so high, like 2168 per monthly, monthly, before they'll cover anything. and the to a doctor doctor wants big deductibles. the deductible to see the doctor, they tell you to the hospital, which i've been doing off and on since 1998. the size ofin tumor a golf ball right outside the brain. chronic an enlarged prostate gland, i've had removed, but er they sent you to the hospital won't wait on you at all. medicare is a sham, too, these medicare, they deductibles, they want you to meet payment to them, besides premiums you pay, which make it hard for people on medicare. host: all right. start with you. complicated questions. caller in he second florida, every state is different, as bruce mentioned earlier. states and six territories, different plans, what medicaid requirements are contribution limits depend, they make you contribute to the cost of your care depe depending on your income and offset with your social security check. i'm not that familiar with florida. media gap or supplemental is private insurance, lightly regulated by the federal limit depend, they make you contribute to the cost government, nothing to do with medicare. is basically gap filler. when you buy a plan from blue or mutual of omaha, private insurance plans, one of y biggest problems with medicare, i like medicare advantage, i never liked medigap. i was promoter of advantage and we put it 2000 in 2003 medicare, asecause wonderful as it is, has high deductible and copayments and a of people buy medigap to pay for that. expensive, they can in fact, depending what state you are, pre-existing limitations.other i think one comprehensive humana, or blue cross, medicare advantage covers all that together in one package deal.better you have seen patients, gone through 4% on medicare advantage to 32% and 50% of lower income private healthcare plan tis a better package. do with nothing to medicare. it is a wrap-around package and its is in most place not -- in?: can you weigh guest: medigap is important to of medicare supplemental beneficiaries, me and my wife, for example. on ite continuing attacks scully and so forth. medicareeen overpaying throughout the history of their really ent in response to some of the distortions and impact rmation about the of medigap policy. my reaction to both gentleman, from being sympathetic and problems ing what the re is the not entirely facetious decision they should move to new york wrshgs we do medigap policies to limit coverage or pre-existing beentions when someone has continuously insured for a year medigap and where rograms require people requiring chronic care for disability are substantially better. that rk is not alone in regard, i might add. frankly, if you and i'm long enough out of politics, ki say his safely, if you had to rank the quality of medicaid programs state by state across the country, both florida and west virginia would be close to the bottom. and that raises the further question as to whether it would terms of prudent in protection of beneficiaries for the congress under per state by state across thecapita cap formula or block grant or states moregive the discretion over how they manage now.caid than they have because even with the existing of federal regulation and number ons, there are a of them that do a pretty mediocre job. ost: a question for you, mr. scully, from a viewer following on twitter. in medicare people receive more in benefits than paid into the system? on is from jay sanders twitter. guest: yes. you pay taxes in your whole life a and pay premium to part b o. average this year, people various levels of cost, on average medicare benefit is worth about, value of the payment, is bout $14,000 a year, you pay $100 in peoplium. average beneficiary today pay $1000 to $1200 in part b premium $14,000 insurance benefit. a.ust fund for part persons getting medicare are getting more out than paid in, es, significant subsidy out of the general treasury. people love medicare, it is a wonderful program. it is an insurance program you are roughly getting federal 90%.dy a little over host: brian from madison, ohio, uestion about medicare or medicaid. go ahead, brian. caller: good morning, john and gentlemen. thank you brian for having foresight to bring c-span along days and i have a experience. in '90-'95, i lived in nevada, regulation, costs were out of control. i was hit by a drunk triefr, broke me. i come to ohio, which has a wonderful healthcare. have private insurance, va care and i have the coverage, of all three, the va is the worst without question. but, what is wonderful about aving all three is that i'm covered pretty much for and the, no extra bills ohio ranked really high our healthcare and i think that there is a lot that learned from states that rovide very well, very good healthcare to fix whatever problems the aca has. host: mr. vladek, on learning states? guest: i think your point is well taken. it.nk you for and the issue of the large the e of variation among states and the way they regulate theate health insurance and way they administer the medicaid program has been a concern to involved in health policy for many years. care act created standardization, especially in the regulation of a private health insurance. so it defines, for example, a basic benefit package. it limits so-called medical nderwriting where health insurer can refuse to ensure you cancer ore history of other chronic duce or so on and so forth. we of the continues ment ras hear from republicans, sort of ideological spectrum within the republican party is esirability of giving more responsibility to the states, limiting federal direction and oversight both private health insurance and of the medicaid program and my concern that it would exacerbate the problems you identified in nevada or the kind of problems the previous caller had, where the quality of the access re you get your to health insurance at any given level of income or any employment status is view, a -- in my unacceptably large extent function of where you live. 20 minutes left in this round table. want to get to as many calls as can. several callers lined up. we'll do two in a row and back scully.mr. murray, good morning. caller: i watch c-span. very informative. -- directed at mr. scully and vladek as to previous how it affects the remarks they have been making this morning. 'm speaking from personal experience, i'm 81 years of age. i respondent 35 years of my life in the insurance business and within my own family, people since birth abled and how insurance has affected them. people in the medical ield, okay, who experienced very, very bad things as a result of the power of the of them.d the rest okay. the other very particular point serious is , very very fact it has been announced on the t.v., radio and newspapers, everywhere, where our life expectancy, mr. scully, down, okay. it is less than what it was before. you're well informed individual you know all the facts which attribute to that result, can spend 1.5 tomahawk ollars on a miss and i will mill carry complex absorbs anywhere by 55 62% of our budget, that is a bad statement for a country hat claim we are going to be greater. i think we lost some values because christian nation, we came in with nothing and we're going to leave with and we're going to be judged by the way we care for between.her in host: i'll let you think about your answer to murray and hear brian in iowa. good morning. caller: hi, good morning. i have three very quick comments. affordable care act, mr. scully said democrats think it is just fine. i haven't heard any democrat say it is fine, i've heard them say fixed, that is a convenient lie. i was 21 bled when years old in a car accident, which was not my fault. on $800 a month for years and my final comment is, if we had single-payer healthcare and companies insurance and instead paid $100 a month in to have the x government provide us our be in -- it e'd would be a much better thing. scully, couple comments for you. -- i i'm supportive for disagree on big-picture hilosophy, i spent my life working on disability, medicare, you are disabled, i think the state government and government should provide you with as much care you can. subsidized and how much? most people i know, god bless accident,were in a car disabled, 1000% behind giving you as much support as cuget. people i know, know somebody wandering around their on , they think, you are social security and disability, have you to be kidding me. people to find the right to support and where, the aca, or anything else. get into issues of disability, i'm supportive of that. single-payer, here is the issue in insurance. blue cross plans, for example, run medicare, a single-payer program. do you want to pay blue cross, pick maryland, blue cross of maryland runs most medicare program, the fact they do. 10 blue cross plans run medicare. want the federal checkbook setting prices doctors pay them to id and write checks? that is how medicare works. tell the blue r cross plan, here is $15,000, you is how isk, that medicare advantage works. most people believe price fixing has never worked in any society and giving third-party risk and regulating them well is more efficient. that is the issue between single payer and private insurance, i third-party have get the risk and manage the program. going back to the other issue and my back tlt ground bruce's. i worked in senate for a senator from washington state. the white house working for president obama in the white doing healthcare from 1989 to 2003. ran cmsack later on and for george w. bush later. i've been in the policy world time.long i currently work in new york for investment firm, not involved in politics, we invest in healthcare companies, the last 10 or 12 years i've been doing that. i hope my biases are, i'm sensitive to the programs, i i believe we m, should subsidize poor people, disabled people and people of income. who do you subsidize how much? subsidizingblem aca 67% of americans. we don't give food stamps to 67% americans. we have to decide who gets subsidized how much for what, who do the tough issue, you support? host: john in sebring, florida. you doing? i got a couple comments. first, i'm on medicare and pay a supplement. it is really good. i love it. been on it for 10 years and second comment is, obama has let somalians and foreigners come in and once they get off the plane, covered under our medicare and supplement, our social security, they have never into, they are breaking the system. do it.lowing them to the last bunch, seven different -- or nine different of.es, took it out and these illegals come in and benefits that the we paid in to and please do not gone, everybodyt knows they are. host: can you -- uest: medicare, have you to have a certain number of quarters to work, not possible to get on medicare. can through disability and supplemental security income. there may be some people, i is hard to -- immigration issue and i'm not want to get into that one. host: some people? million? guest: bruce and i disagree, 4.5 million to 9 million in the last and there is debate who should be on there. i am supportive of people on disability. i've been involved in medicare and disability for 30 years, it the wonderful program for right people, it is great. i have zero problem with someone on disability get og disability. a couple court rulings the last opened up qualification significantly, more people are let in. massive programs, your tax dollars and we should support and subsidize people who should be appropriately subsidized. at some point, you need to make get -- who needs to host: the question about illegal mmigrants getting on some programs specifically, medicaid scully was talking about. do you know how often that happens? s this a million -- guest: really never -- the on eligibility for public programs not only for aliens, but for legal aliens in the united states for years is enforced routinely and effectively. suggest that the are r of illegals who receiving health insurance of ny kind is actually historically greater in the private sector than among public programs. i was out of touch for about technicales, we had a problem. if i may, i would like to respond to the earlier well, and the s comments. what the gentleman said from new was, about ess it reduced life expectancy in the united states in 2014 and the gentleman from dubuqe said reminded me that while we really know why life expectancy in the united states facts remain the among the wealthy industrialized the ned of the world, united states is the only one that doesn't have government and many cases, overnment administered universal health insurance and the only one according to news reports on life expectancy in expectancy fell in 2014. it is also significant that all countries spend substantially lower proportion healthcareconomies on than we do in the united states. now i'm not saying i should have government-run healthcare in the united states, i'm not saying we should have a single payer in the united states, but i am saying somehow every other ndustrialized country has managed to do a better job of eeting the difficult conflicting goals of covering everyone providing high cost to them, producing good outcomes from the keeping e system and the cost within reasonable bounds. only in the united states have do that and toto me that is fundamentally a political problem. running out of time. mary has been waiting in winterville, north carolina. are on with tom scully and bruce vladeck. wondering if was y'all are aware if any of the rates have gone up? scully.. exact bruce may know the number. premiums or to rates that provider?pays host: she hung up. fw ahead. uest: premiums for most beneficiaries went up a very year, compared to last year. there are two categories of for whom they want more. who are in re those the top 10 or 15% of income medicare beneficiaries who surtax hasax and that gone up n. addition to which in e has been higher bump premiums for people coming into the program in 2017 for the time. but for most beneficiaries, the forget the ease, i exact number, in the low single digits. two, we have a minute or jop lin, missouri, liam, can you quick?ur question caller: yeah. affordable care act, isn't that that richard nixon put up? hy do republicans hate it so much? and, that is my question. scully.r. guest: i don't think republicans hate it, they think it was out spending was too much, benefits was too much, the thing passed on partisan basis ago.years the issue going forward, with a lot of calls, medicare is not touched, unlikely touched in any meaningful way. about scale bate back affordable care act, scale ack exchanges, scale back medicaid expansion. bruce will not like it, politically that is where we are. constructive bipartisan discussion about how to shrink this thing. shrink in way that doesn't affect people who healthcare support. ost: mr. black, last 60 seconds. guest: one, the affordable care ct was a modeled on a health plan adopted in massachusetts who republican governor principle health advisor is the republican governor of massachusetts. howink that says more about the republican party has shifted since the time of president logistics about how of healthcare or healthcare policy have changed. republicans can repeal obamacare and not take away coverage from some of the million people who have obamacare or er cutback on the benefits that reproductive age or people with psychiatric problems who have employer-based insurance getting under obamacare, more power to them f. they do square the circle and prove that humans have nothing to do with global warming. host: we'll have to end it there. ahead.go guest: the government is just a friend of mine, i was involved -- look, i love romney, massachusetts waiver was expanded, not one enny from massachusetts, that was through federal financing scam, as most of them are. fiscally e responsible. host: debate we can continue time.er and cully joining us in dc vladeck in new york city. appreciate your time. "washington journal," we'll end with open phones public policy ny issue you want to discuss. we will continue the discussion about affordable care act or any other topic. republicans, 202-748-8001. democrats, 202-748-8000. independents, 202-748-8002. now.can start call nothing we'll be right back. >> affordable care act has done what it was designed to do, it us affordable healthcare. so what is the problem? why is there still such a fuss? well, part of the problem is the fact a democratic president passed the obama law. [applause] >> and that's just the truth, i really, really hard to engage republicans, took ideas that originally let's d praised, said, work together to get this done to doen they just refused anything, we said, all right, we'll have to do it with is what we d that did. and early on, republicans just decided to oppose it. then they tried to scare people with predictions, that it would job killer, that it would force everyone into government-run insurance, that would lead to rationing, lead o death panels, that it would bankrupt the federal government. you remember all of this? and despite the fact that all the bad things they predicted actually happened, despite the fact that we've billed more jobs since the passed than in consecutive record, an any time on the te the fact that uninsured rate has gone down to despite t levels ever, the fact it cost less than anticipated and has disruptive much less on existing plans, the people employers, heir espite the fact it saved , dicare over $150 billion makes that program more secure, despite all this, it's been hard, if not impossible, for any republican to admit it. they just can't admit that a lot of good things have happened and the bad things they predicted didn't happen. repeating, keep on we're going to repeal it, repeal somethinglace it with better, even though six and a half years later, they still haven't shown us what it is they do that would be better. >> announcer: "washington journal" continues. host: for the last 25 minutes or "washington ng on journal," it is open phones, talking about any public policy issue that you want to discuss. phone numbers are, republicans, 202-748-8001. 202-748-8000. independents, 202-748-8002. it.s get right to harry is in harvey lake, pennsylvania, a republican. good morning. caller: good morning. i'm waiting for you guys to talk thing about sian tampering with the election in the national media making a big deal. failed to mention the fact hat we've had 40,000 nato troops in -- working six miles oth in the czech republic, conducting more games for the last four months now. was putin, i would want to resume change in the country, too. the if they showed up on coast with destroyers, don't you think the american people would outraged? not a word in the press. we depend on you at c-span to the questions. host: appreciate the call. bring our viewers up to the topic.on this this story making front page of everal major papers this morning. president-elect donald trump escalated fight with u.s. intelligence community on sunday denouncing findings of russian medaling in the u.s. setting up xtraordinary rupture twun soon to be president and his establishment. that is the lead-in story on the front page of the "wall street journal." donald trump was on fox news sunday, yesterday, and was asked report of russian involvement in the u.s. election. here is what he had to say. ridiculous, is just another excuse. it.n't believe i don't know why, and i continuing is just, they talked of things, every week another excuse. we had a massive landslide know, in the u electoral college. guess the final numbers are 306, and down to a very low number. at all.n't believe that >> you don't know why, do you think the cia is trying to the results to weaken you in office? >> if you look at the story and they said there, is great confusion, nobody really knows. hacking is very interesting, they hack, you don't catch them in the act, you will not catch them. it is ve no idea if russia or china or somebody, it could be somebody sitting in a some place, no idea. >> why would the cia put out a you to e russians want elect -- >> i am not sure they put it putting it ats are the they suffered one of greatest defeat necessary history. get back to making america great again, which is what we're going to do and we have started the process. host: the "washington post" in their story on this subject, the headline "glowing call noting e of russia," senator john mccain, and senator joined democratic leader charles schumer and jack reid for bipartisan investigation of russian interference in the u.s. election. two days ement came after "washington post" reported russia ate conclusion activities were intended to tip the scales to help donald trump. "new yorkboard of the times" also editorializing on this topic this morning. headline, russian hand in america remove s -- only way to the darkening cloud over his presidency, failing to resolve russia would t seed suspension among millions americans. the election was indeed rigged. hearing your thoughts and comments. kevin in washington, d.c., a kevin, good morning. caller: good morning. just to talk about the issue talking about now, ussia's latelyinged involvement. hack suggest a big deal, we need o find out if anybody who did this, get to the bottom of it. but from what i understand, was people, they were the vehicle or the channel in a lot of the information came from. funny how don't want to talk content of the -mails, talking about how the democratic committee stole the election from bernie sanders who would have liked -- donald polls that is what the said. let's get back to content, yes, matters. is ress should vote -- that my first point. we're not t, republic republicans going to wake up? wages, talk about manufacturing jobs. in order to get strong wages from the manufacturing jobs, we need to have strong unions. we have donald trump, a man w leader and talked about how minimum wage to be abolished. why don't republicans -- host: kevin, you are calling in on the republican line. another upport candidate in the republican primary? didn't vote for neither of the candidates. you know, actually i supported bernie sanders. independent. e felt like he was, you know, moral morally and all about socialism, look at your roads, highways, your public schools, look at your fire and policemen, all the tactics that re was a mess. host: line for independents, dennis, good morning. caller: good morning. yeah, i wanted to bring up an the f.d.a. allows. lotink we need to look at a of research they did in europe, chemicals s caused allowed in american food that in a lot of ed european foods and there are of illness seem to be better than ours. i think a lot has to do what the allows in food. so chemicals allowed currently looked at more closely and we don't really need studies, studies have been done by europe. you know, you look at whole trader joe's and they research and don't sell foods that are generally unhealthy. go to other corporate supermarkets, i don't want to mention names, but the big one, they sell all these chemicals additives and hormones and things making us sick. to stop that and get on the f.d.a. about it and also stories about know, factors and -- you people know what is going on and know the issues and legislation caused by that was that hysteria, we need to stop that, too. f.d.a., ry on the future of the f.d.a. and donald trump's potential head of the from the hill newspaper, trump rumored candidate strikes headline. the the possibility that could nt-elect trump elect jim neil, as head of the off alarm etting bells among some healthcare experts. read more on the story hills newspaper. mary joe allen in fort a hington, maryland, democrat. good morning. caller: good morning. well, my comment is, i just want to go and throw up on everything i hear. itald trump said, excuse me, said he wanted to drain the swamp. swamp, he rain the drained the klan, this is a ku lux klan and it looks like racist people want a race war f. hat happens, those particular people would lose, we have many, many people that want to work together to make this a peaceful country. ost: mary jo, what would draining the swamp mean to you? caller: draining the swamp means ills happening in congress right now. he is the swamp. what?such as caller: corruption. our government, not the government, our political corrupted, it is just disgusting. have turned off all of the main news. by the way, we're not afraid, putting out ps we're afraid and let's move on and accept. as ll not accept this thing president of anything. lands on him te when he's in inauguration. host: all right. republican, good morning. caller: good morning. for c-span and who we should have elected for brian lamb, that is another story. -- let's assume for a moment that the russians did try to influence our which is a good possibility. the assumption then is they did to help donald trump and i think it is pretty clear they fthey did it, did it to hurt hillary clinton who opposed running for re-election. levers of w what power she used to discourage putin, from voting for but he's probably decided to use levers he has to for e her running president. host: all right. to rob in laurel, maryland, democrat. good morning, it is open phones. caller: good morning. i want to mention something he about.st talking hamilton '68 eliminates orruption involved in the presidential vote. this election appears to be like sort d looks of -- the u.s. and rauszia done banana republic election work before. time either blatantly engaged against the other. electoral the delegates purposely and wisely, might add, by founders, unbound, now have the honorable duty to ensure democracy in the before an attack. the u.s. history attainments in we the d treasure by people. we the people. is testimony to the sanctity of majority vote, democracy in distress, defend the united constitution. a quote from hamilton. electoral the college is "prevent individuals unfit for a variety of reasons, o be in the position of chief executive of the country," alex hamilton,two page, take a read. host: rob, speaking of the electoral college, electors op eds by questioning the idea of staying faithful to the vote in their state. here is one today by ashley kansas hutchison, republican party on why she's staying faithful to donald trump. told me to act s faithless elector and stop mr. trump from taking over the presidency. electors have broken their pledge and voted for alternate candidate or abstained from voting, according to fair vote. there is a reason this tactic has never been successful, she worst of assumes the americans. letter writers are asking me to my own people because they are supposedly racist and easily fooled. i don't buy it. won't violate the will of the people of kansas because they trump tweets too much. i noticed a theme in thousands of misses i received, they don't understand or persuade, only to insist. most of these people want it want it now. mother of two small children, i that.how to handle mcmillian hutchison. south carolina, independent. good morning. caller: good morning. host: go ahead. how are you today? host: doing well. caller: well, i would like to little bit more about some things that previous open callers have mentioned upon. they talked about influence by elections, .s. things like hacking, also some people talking about the a few of papers and the founding fathers. a lot of what is being discussed main-stream media about influence of foreign can s in our elections really be resolved by looking at well washington's fare address to the nation. after he served two terms as wrote a letter and the tradition was carried on with later presidents. feel like washington's letter a most powerful and he has piece from the letter that he arns nation of powers of political parties in the state and it reads this way. i have already intended the danger of parties in the state with particular reference to the founding of them on geographical iscrimination, let me take a comprehensive view and warn in maern against effects of party generally. this spirit unfortunately is nature.ble from having truth in strongest assion of the human mind, it exists under different shapes and all governments more or less stifled, controlled or oshg pressed, but those of the opular form, it is seen in greatest greatness and truly their worst enemy. of oneernate combination faction over another sharpened by spirit of revenge, natural to party dissension, affecting different ages and countries horrid enormity and death to them. graham in south carolina. republican, teresa, good morning. caller: hi. had called to speak to you regarding medicare, is that okay to -- tis open ectly fine phones. caller: isn't it true that mr., president obama took 2.17 billion dollars out of medicare to start up the program? this new healthcare program. -- iiving in florida, i am became disabled, i became totally lind, almost blind. years, i working 25 just, it is difficult for people on less than $800 or a month, ar, i mean i'm sorry. when they take out our premium, harder.en just want to say, i hope mr. trump does get confirmed, i is the word, looking for, i don't know what the big to-do about it. host: you mean sworn in? caller: yes. don't understand why people are upset. people weren't happy when president obama got go to theut we didn't lengths that other people have gone to, you know. teresa, on the issue of the affordable care act and its headlines re is some from some papers from around the country today, i wanted to show you. the sacramento paper, new push obamacare reignites old tension in the gop is headline of that page. it is a picture of hatch, utah, who favors extended transition process in affordable g of the care act that accompanies that photo. another headline from the herald of indiana, advocates worry about losing obamacare is you want to re, if read that in the herald bullet. tribune, states may be tested by repeal of aca, difficult budget choices likely, the front page headlines this morning. in open phones. matthew is in georgia, an independent. good morning. caller: good morning, how you doing? fake news, i just found this out, abc stand for broadcasting crap. nbc, nothing but crap. crap between the. host: okay. texas, , lake dallas, republican. ann, good morning. caller: good morning. for ncern is that the years, you know, we've been we've been and hacking and russia has been hacking and other countries years and it is just a fact of life. we should have safeguards and don't.nd we we are so busy cutting each other down, we're not doing what we need to. that even obama ontributing $250,000 to get netannahu from getting reelected. was inant to note, hatch the picture from the front page of the sacramento paper on front commentary section today hatch's words, he wrote, a about the nomination of jeff sessions as attorney want to read u that, it is in today's washington times commentary section. in coreyville, pennsylvania, a republican. go ahead. very muchs, thank you for taking my phone call. democrats cans and thought it was a joke when mr. trump said he was going to run presidency blican nominee. nd you have done everything that you possibly can to him now, here we are, he was elected the president, understands why. cannot accept the fact that mr. trump won the election. news media can't believe he election. and here's a woman who made e-mails disappear, she had the f.b.i. say she was a bad hair day, so we're not going to charge her with anything. i would not put nothing past hackings that are supposed to have taken place believe ia, i would would be nothing, but her knows to e people she put this in place. we have ew tweets as the conversation about stories about hacking, american hero writes in, define interference how is that different from having a preference? wanted ssible russians to avoid world war iii. rick says trump's assertion the cia are wrong e and they know nothing is more trape he always uses. go ahead.ndependents, it is very interesting that the people that are so willing to cut funding for people that have so little money are so comfortable with it. my daughter was very ill, and providers health care -- she was turning from yellow to green.

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