America in the Trump Era: The Future of Health Care

America in the Trump Era: The Future of Health Care


[BEEPING] Good evening. Welcome to the
latest installment of the Institute of Politics
Exploration of America in the Trump Era. Tonight, we’re going to
take on what is perhaps the most hotly debated
issue of this period, which is health care. And as you will hear,
we have as good a panel as one could assemble to discuss
this issue with Nancy-Ann DeParle, who was an architect
of the Affordable Care Act, and Governor Mike
Leavitt, Former Secretary of Health and Human Services. And we have a great
introducer who will fill in some of those details. Next week, next
Thursday, right here, we’ll have a discussion led by
Robert Costa of The Washington Post on the future of
the Republican Party. And then on the
27th of February, we’ll have a discussion
on the future of the Democratic Party
with leading Republican and Democratic politicians. And you can find
additional information about upcoming
events on our website at politics.uchicago.edu. As always, after our
moderated discussion we’ll be taking questions
from the audience. And as always, we’re going to
demand that they be questions. And we’ll prioritize students
for the first three questions. So please keep your questions
short and to the point, and end them in a question mark. Silence your cell phones. And now, to formally
introduce our guests is Alessandro Clark-Ansani. Ale is a second-year
in the college studying political science
and public policy, and serves as the Fellows Intern
at the Institute of Politics. Ale. [APPLAUSE] Good evening, everyone,
and welcome to “America in the Trump Era– The Future of Health Care.” President Obama
campaigned and governed on the idea of making health
care more affordable and more accessible to
everyday Americans. While conservatives
and liberals alike can agree that the Affordable
Health Care was not perfect, as few legislation
and policies are, it is a fact that today, many
Americans who were previously uninsured have coverage. However, President Trump
and many other Republican politicians have vowed
to repeal and replace this legislation but
have yet to offer the new legislation in writing. Tonight, we are joined by
Former Governor of Utah and Former US Secretary of
Health and Human Services Michael Leavitt and Former
Director of the White House Office of Health Reform,
Nancy-Ann DeParle, two individuals who have
had extensive exposure and experience with
government-provided health care. Governor Leavitt served under
President George W. Bush and was involved with
attempts to improve Medicare and Medicaid, particularly in
regards to prescription drugs. Dr. DeParle served in
the Obama administration, helping to lead the
administration’s health care reform, including the passing of
the Affordable Health Care Act. We’re also joined by
visiting fellow Jackie Calmes, a former New
York Times journalist who covered the White House
during the first five years of the Obama administration. As elected officials weigh
the options regarding the future of health care,
hopefully these guests can help shed some light
on possible outcomes. Please join me in a
warm round of applause in welcoming our speakers. [APPLAUSE] These are big chairs. Yes, they are. I have that Roseanne
Roseannadanna feeling here. Good evening. Thanks for so many
people being here. I’m going to start tonight
with sort of a vent, the perspective of a
politics and policy reporter of long standing, and
the frustration journalists like me would have over
the years at having to quote politicians
who’d promise something they knew couldn’t be
done and wouldn’t be done. And yet, you could never
write that in so many words. You couldn’t make that
judgment in a news story. And the best example
of what I’m talking about for the past
seven years has been the promise to repeal and
replace the Affordable Care Act. And yes, there are some
members of Congress who were sincere in
wanting to repeal it and thinking that was possible
without huge disruption to industries and to people. But a lot of them
knew better, frankly. And now that they’re in
full control in Washington, the repeal-and-replace
dogs are sort of like the dogs that
caught the car, and they don’t know what to do. And the consternation has been
clear for the last few weeks. And I just want to
give you one example before I turn to questions. On January 10, President
Trump– well, this was before he was president–
told The New York Times that he wanted a repeal vote “next
week,” quote unquote, and “replacement” quote
unquote simultaneously. And he didn’t have
a replacement then, and neither does Congress. Congress did vote to
start the repeal process, without an alternative. And that legislation, which
didn’t need his signature, directed the committees to write
a replacement by January 27. [LAUGHTER] Yeah, it’s February 8. So in recent days,
President Trump told Bill O’Reilly
that something would quote come quote, “by
the end of the year, at least the rudiments,” unquote. Now, few people in the country
know more than these two people about health care policy
and the difficulty of making it and implementing it. So I’m going to turn
first to Governor Leavitt, because you’re of the
party that’s in power, and ask you to tell me– tell us– how this
is going to play out and how it’s going to end. Just a small, quick question. [LAUGHTER] So as you were asking
in your earlier comment, my mind was carried back to a
moment in time when it was 2012 and we were engaged in a
campaign for president. President Obama
was the incumbent and Mitt Romney
was the challenger. And in April of that year,
he called me on the phone and said, we need to
have some thoughts about what we’re going to do
after in terms of planning. Would you chair the
transition for what we hoped would be the
Romney administration? And I agreed. One of the first
things we did was to make a list of
all the commitments that had been made
by candidate Romney, with the idea that there
would be an obligation to actually do those things. And one of those commitments was
that we will repeal and replace Obamacare, or the
Affordable Care Act. And so we actually formed
a quite elaborate process of planning this transition. We took it very seriously. And one of the questions
that was posed very early is, what does it mean to
repeal and replace Obamacare? Well, it became
evident to me– and I’m sure it was to most of
the rest of the world– you can’t pretend
that a law didn’t exist for a period of time. But that this phrase,
“repeal and replace,” is essentially a big principle
that means a lot of things to a lot of people,
and the literal removal of the law like it didn’t
exist isn’t one of those. Now, I will tell you that
the decision that I made was there would be
a moment in time when there was, at that point,
probably a reasonable thing to have a bill that said
it would be repealed. But it would fail,
because we would likely have a divided government. And at that point, we then
had to go through a process where we would define what
the word “repeal” meant and we would define what the
word “replace” meant. Now, the circumstance they
find themselves in today is not measurably
different than that. And what we’re seeing
them go through is a process that I think
is not substantially different than that. The one thing you
can be certain of is that at some
point in time, there will be a bill that
will pass Congress. And the title of that bill
will be “repeal and replace,” because they have dined out
on that phrase for six years. They have been rewarded in
three subsequent elections for that phrase. And they have an
obligation to fulfill it. Now, some people may have
in their mind a list this long when it comes to the
things that will be repealed. The likelihood is it will
be shorter than that. There’s a long list
of things that people believe should be replaced. And the likelihood is the list
will be shorter than that. In the context of
history, when we try to ground truth
what is happening now and in the last
decade or two, it’s very important not to think
of health care transformation as being about the Obama
years or the Trump years. We have to acknowledge that
this is a 40-year process, and we’re about
25 years into it. And what we’re seeing is
iterations in history. Now, we will see changes occur
to the Affordable Care Act. And I think you have to give
credit to President Obama that he passed something. And it got change started in
a way that it hadn’t before. But frankly, there
are things that need to change with
the Affordable Care Act and that needs to iterate. And in this really ham-handed
thing we call our democracy, this is the way we do things. And we will begin to
iterate, and over time it will continue to change. But you have to look at
this in a longer time frame than just a
narrow period of time compared to another
narrow period of time. So Nancy, how do you see this
ending from your vantage? Well, the first part of my
friend Governor Leavitt’s answer made me feel like Alice
in Wonderland a little bit. I do think you’re
probably right. The Republicans in Congress
and President Trump have gotten themselves
into a corner here where they have
to pass something that they say is a repeal. I do worry, though, that
having that conversation is having the opposite
effect that they say they want on the markets
and on our health care system. They say they want
everyone to be covered– and beautifully covered,
as President Trump puts it– and lower costs,
and this ideal world. And as you say,
Governor, there certainly are changes that can be made
to the Affordable Care Act. You and I have spent
time talking about them. And I had a list a mile long
right after the bill passed of things that I would do. And what you would
typically do– Jackie, you’ve been
around these processes. Typically, after you pass a
major piece of legislation, you have a technicals law. When we did the Balance
Budget Act in the ’90s, we then came back with
the balanced budget, BBRA, the Balanced
Budget-something Repair Act. Then we did the BIPA, the
budget improvement act. So there’s things you do to fix
the unintended consequences, to strengthen some pieces. No, you’re right. Throughout my career– I can go back to the 1986 Tax
Reform Act of Ronald Reagan. There were several
technical corrections. Because whenever you have big
comprehensive legislation, everybody assumes there
will be fixes to make. And the Medicare
prescription drug benefit law that was passed in
2003– there were technical corrections to
that, weren’t there, Governor? Yes, a lot of them. And a lot were needed. And I don’t think
there’s anyone– And you did a great job with it. –that would disagree
that ACA didn’t need– Right. So I just think my
only disagreement– it seems a little
surreal that they have to go through this
process of calling something “repeal” when when
you actually look at the pieces of the
Affordable Care Act, it was based on many
years of bipartisan work to come up with
what is a uniquely American way of solving these
problems of cost of health care being out of control, of
trying to get everyone covered, of dealing with preexisting
condition exclusions and all the insurance market
dysfunction out there. And we did it in a way that, for
the most part– not completely, but for the most part–
was built on the foundation that we had and was bipartisan. And so I was looking earlier– the final Senate bill had 167
Republican amendments in it. So there should
have been a basis there to just take
that, and let’s sit down and figure out how
to repair this. Senator Patty Murray
said something recently that, really, I felt was
evocative about it, which is it’s sort of hard to repair
the roof when they’re burning the house down underneath. And that’s kind
of how this feels. And I don’t think
it’s really necessary. And what worries me is
the number of people calling the marketplaces
asking, should I still sign up for this? That’s going to discourage– the thing that needs to happen
right now– and Governor Leavitt has some very
specific ideas that I think are the right ones on how to
strengthen the marketplaces– that’s what needs to happen. We need to make sure that
the younger, healthier people are enrolling so that they
work, so that insurers will feel like they can make a
profit there, and will come in. And there’s things like
that that need to happen. And the actions of
an executive order which suggests that maybe
the law won’t be enforced, and removing the frankly
relatively paltry sum left of several million
dollars to do the marketing and enrollment in
the last two weeks of the enrollment period– those aren’t the
things you do when you want to strengthen this,
stabilize it, and then move forward. So that’s what worries me. Could I just make a point? This is politics. And it can’t be
logically rationalized. [LAUGHTER] Campaigns– I mean,
one of the things that was very important
for me to learn is that you can
explain Washington with, really, two things. One is that it’s
all about preparing for the next election. And it’s control
of the news cycle. And campaigns are
run with big themes. And sometimes those
themes expand way beyond the scope of
whatever that theme is. I mean, one of the famous ones
is a chicken in every pot. What does that mean? Well, it became a rallying cry
over a lot of different things. And that’s what repeal
and replace became. It is not about
health care alone. It’s about control
of the government. And it’s a symbol of what
people want the government to look like and feel like. And it was a way of rejecting. It became a big symbol that
people were arguing over. So if it became LeavittCare
in Utah or in Kentucky it was KentuckyCare,
KCare, RomneyCare– that is more popular generally
with people than thinking it’s a federal government solution. I think that’s part
of what’s here. I think what people were
rejecting wasn’t just the Affordable Care Act. It was a dysfunctional
government. And the Republicans made a
symbol out of the Affordable Care Act that said,
this is dysfunctional and I want government
that works. And that’s why it became
an overall broad theme that they drove. Now, I’m not defending it. I’m just saying
that’s the way I think you have to see this debate. And so yes, they now have to
reconcile to their broad theme. And the logical way
for them to do it is to get the list as
long as they can on repeal and as long as they
can on replace. But the reality is,
when it gets down to coming up with 435
votes and 51 votes, or 60, the list is going to
be smaller than that. And they will with a
good conscience say, we did the best we can
to repeal and replace. But it was a much bigger theme
for them than just health care. Well, we could get into a
longer discussion about how much of the dysfunction is sort
of a self-fulfilling prophecy by the opposition and
obstruction to the plan– and then implementing it,
because I have to think you have some sympathy, having tried
to put through the Medicare prescription drug– stand that up from ground zero– and the idea of doing
that with people through the whole time
trying to kill it would be would be daunting, wouldn’t it? This was a fascinating
personal experience for me. Now, what she’s
relating is that I was responsible to
bring 43 million people a new prescription drug benefit. Not just people– seniors. Seniors. That’s even harder, right? I mean, you brought up politics. Very special people of
which I am now among. And during the first 12
weeks or so, it was a mess. We had people lining
up at their pharmacies and they couldn’t
get their drugs. This is a long story, except
that during that 13 or 12 weeks a whole series of attacks
were made on that program. And they needed to roll it
back, and we needed to stop, and blah, blah,
blah, blah, blah. Then roll forward to the rollout
of the Affordable Care Act. Exactly the same arguments
are being made against it. My point is that these things,
these arguments, are made, and the same arguments tend– they’ll just flip, because it’s
all about the next election and control of the news cycle. And so I don’t think you can– again, I’m not defending this. But it’s a very real factor
in the way politics works, because it’s not just
about health care. It’s about big,
broad themes that lead to control of the
government, which can then extend into lots of
different places. And so any campaign tends to
look for the big, broad themes. And they drive them. Let me go to a question that I
wasn’t sure I was going to ask. But Nancy, you talked about how
to strengthen the marketplaces, and we need more healthy
people, to attract more healthy and young people
whose insurance premiums will offset the costs of
serving the sicker people. And the key to that is
the individual mandate. Now, that is the core of the ACA
that the Republicans have most objected to, I think. And I don’t know if that’ll
make your short list of what will be there in the end. I assume it won’t be there. But then the question
is, what’s there instead? But I want to go back. The years you were
governor of Utah were the years that
President Clinton and Hillary Clinton were trying to
pass their health care law. And I was covering Congress at
that point for The Wall Street Journal. And the Democrats were– the plan called for
an employer mandate, that employers were mandated
to cover their employees. The Republican alternative in
the Senate, led by Robert Dole, was an individual mandate,
for individual responsibility. And I’m just curious,
because I honestly don’t know the answer to this
question, could you just– I mean, briefly–
tell me, when did Republicans move from that idea
of individual responsibility slash individual
mandate to opposing it? Well, I used an example just
a moment ago of a lot of times when people begin to just
change their arguments, change from one
party to the next, it’s typically because
they’re against it now when they might have been for it. I mean, I’ll give you
a really good example that I think is current. For many years over
the last six years, the Republicans have argued
about a part of the Affordable Care Act called the CMMI,
Center for Medicaid and Medicare Innovation. And it was a very broad
extension of authority to the Secretary of Health to
be able to essentially write the law the way they wanted
to in specific situations to innovate. The Republicans hated it. They hated that
much authority being in the hands of an
unelected person who would move the system
in a way that was not consistent with their ideology. We have an election,
and now there’s something different about it. And that is, who
actually holds that pen? Now it’s a very
attractive authority, and the Democrats
are attacking it and the Republicans
are defending it. And now it isn’t on the
list to be repealed. And it’s not on the
list to be repealed. It’s funny about that. Now, exchanges is
another example. David and I were talking
about this earlier. If you go back on the
history of exchanges, you can go back to
’92, the Clinton. You were doing it,
from what I remember. Well, the Clinton administration
proposed something that looked a lot like an exchange. They called them co-ops. You go forward about
10– and by the way, the Republicans hated
it and they killed it. 10 years later, the Republicans
came up with a similar idea– it actually came out of
the Heritage Foundation– called exchanges. And the Democrats hated that. Yes, they did. Then you go forward
another five or six years, and we have an election. The writers of the ACA
did a very clever thing. They took the
exchange that looked a lot like Hillary
Clinton had, and they took the name of the exchanges
that the Heritage Foundation came up with and
called them exchanges. And now the
Republicans hated that. So they had a big fight,
and ended up basically saying every state can
decide which they want, one like the Clinton
administration wanted or one like the Heritage Foundation. My point is that if you’re
looking for consistency here, it will be hard to find. The hobgoblin of little minds. One question for both of you. First, Governor Leavitt,
to the differences that Republicans
have among themselves as they undertake this effort– President Trump and some
of his closest advisers have talked about the goal
is universal coverage. The Republicans are
saying universal access to affordable coverage. Those are two very
different things. How are they going
to bridge that? Can they bridge that? Well, I think we ought to start
by acknowledging that there is a widely-held American
aspiration for everyone to have access to affordable insurance. That does not divide us. What does divide us is
exactly how to get it done, how to define it,
what to call it. And words matter a lot here. But I think it’s a
very important point that Republicans
and Democrats do not disagree on whether that’s
a laudable national goal. How will they achieve it? I think I and Nancy-Ann
could lay out pathways where they could achieve it. But we also need to
remember that none of this happens in isolation. Donald Trump’s only commitment
was not repeal and replace. He committed to $1 trillion
of infrastructure investment. He committed to
rebuild the military. Republicans in the
Congress are going to feel very strongly about not
having the national debt become substantially higher. And so all of these
things have to take place in the context of the other. And so there are natural limits. And the reality is,
if you were to ask how that’s going to be
defined, they would probably put a horizon on it and
say, that’s our aspiration. We’re passing the Universal Care
Act, or the Universal Access Act, and we hope to
have it within 12 years. And they’d declare victory. That suggests a question
that both of you can address. In terms of paying for whatever
it is that the Republicans come up with on a health care
alternative, I mean, it is going to cost something. And there is some talk
among some Republicans– I think they’re a
minority at this point– about keeping the taxes that
are in the Affordable Care Act that Republicans have
opposed up to now. The taxes range from
those on medical device taxes in hospitals,
and on wealthy people and on the penalties for
people who don’t buy insurance. All those sources
of revenue, there’s now talk of keeping them
to help finance whatever it is Republicans come up with. Given their concern
about deficits and debt, do either of you see some of
those things in the new law? Well, I do, only because,
as the governor said, the Republicans felt– and
President Obama told us, and the Congress felt– we have to pay for this. In fact, we actually
reduced the deficit over, the numbers I just
saw, $2.6 trillion over the first 10 years of
the Affordable Care Act. So that will be a
tough hurdle, I think. I believe that the
Republicans in Congress are committed to not
increasing the deficit, and it’ll be really
hard to do anything here by getting rid of those taxes. So there’s no other real
way to fund this unless they want to do more Medicare cuts. We did things almost exclusively
from the health care system. I suppose you could put
a tax on something else, but I doubt that
would be popular. So let’s go to some
specific things and answer your question
in the context of that. Nancy and I would agree that
the individual insurance market in our country is
very fragile right now. It could easily– and has
begun to– erode in a way that the 20 million
people who have insurance through the exchanges
and otherwise are in danger. The insurance
companies have said, we’re losing so
much money that we can’t justify to the
nonprofit organizations that we oversee
continuing to do this. And the reason for
that is because there is a very serious set of flaws
in the Affordable Care Act that could be and
should be fixed. And nearly everyone agrees
that they need to be fixed. We now have a different
problem, and that is that the Republicans
own this problem now because they have
the power to fix it. And they’ve made a
commitment that they’re not going to let 20 million
people be left hanging. So they have to fix this. But the reality is the fix
will not happen immediately. It will take two to three years
for that fix to implement. And even if they replace it
with something brilliant, it will take three to four
years for that to happen. Even if they passed
something today, it would take some
time to redo it. So they have to pay for
these 20 million people and the subsidies that are
there for that period of time. Now we’re back to
the $1 trillion of infrastructure,
the rebuilding the military, not
busting the budget, and having things that
Republicans feel strongly about. They’re going to suffer if
they let 20 million people– so the pressures of
all of this dictate only one possible outcome. And that is they’re
going to pass whatever they do is to
replace, they’re going to defer it for
a period of time, they’re going to keep the status
quo in place while they do, and they’re going to have to pay
for that, probably by deferring any tax increases– or I’m sorry, tax reductions–
that they have committed to do. But they’ll still be
able to claim victory, because they will
have put it in place. Now, we’ll see where it goes
three or four years from now. And tax reform is one thing
that wasn’t on your list but that I hear is a
very high priority, tax reform in general. Yes, it is. So if Leader McConnell
wants to do tax reform, that also figures into this mix. Right. So can either of you see
what is the alternative? Up to now, the Republicans have
talked mainly about the ideas that insurance companies
should be able to sell across state lines, number one. And number two, that people
should open health savings accounts that would be a
tax-favored account that would allow them to
buy their own coverage on the private markets. Together, those things
have never added up to covering the same people
that are covered by ACA, and leaves out the whole
question of Medicaid– which roughly covers, I think, isn’t
it about half or a little over half of those 20-some
millions who are newly insured thanks to the ACA. So as an alternative, how
does selling insurance across state lines
and HSA’s stack up? Well, I don’t think it
stacks up very well. Selling insurance
across state lines is an idea that’s been
around for awhile. It actually is something that we
put in the Affordable Care Act. States can do that. Insurance companies can do that. But the states have to agree. So this is a case where we
said, if the state of Utah and the state of
Illinois want to say, we’re going to let insurers sell
in Illinois to Utah and Utah back, they have to agree so that
both insurance commissioners know that it’s going to happen. This is an area where the
insurance commissioners around the country,
Republican and Democrat, agree that it’s not a good
idea, because they think there will be a
race to the bottom– that all the insurers will
want to go to the state with the lowest standards, where
it’s easiest to take advantage of consumers, design
products there, and sell them in other states. So they at least
don’t think it should be something that’s widespread. But if someone wants to try it,
I’m OK with seeing if it works. I don’t think it’s a
solution to this problem. Nor do I think that
HSA’s, which are fine– I have one. A lot of people have them. They tend to work better
for higher-income people, because the money
accumulates in there and you’re less likely to fail
to go get health care because of not having enough
money in your account. So those could be expanded. But I don’t think
they’re the answer for the population of people
who really need help here. So I did not come tonight
to advocate a plan. [LAUGHTER] What I am here to do is
to do my best to say, through the filter
of my mind and eyes, based on what I have
seen and experienced over all these many years, how
do I think this is ultimately, through the shifting sands of
politics, going to turn out. And here’s the way I think
this issue works out. I think the first
thing they have to do is they have to fix the fragile
nature of the individual market or this big problem is
going to become theirs. And they will go in
and repair some things in the Affordable Care Act
that will allow insurance companies a rational reason to
stay in the individual market. That’s important. Can you do that without
an individual mandate? So they’ll then have
to wrestle with that. But let’s say this. We are now about,
I guess, six years into this and the
individual mandate has really never been enforced. And so a lot of
people will argue, you’ve got an individual
mandate but that’s not what’s holding this together. They will likely repeal
the individual mandate, but they’ll replace it
with something ultimately. And there’s a lot
of ways they could. They could do the same
thing we do with Medicare. They could say, when you turn 26
and leave your parents’ policy, you need to buy insurance. Choose if you will or
choose if you won’t. But if you don’t,
just like on Medicare, if you don’t sign
up for Medicare, your Medicare gets 1% a year
more expensive every year. Seniors in this audience
know that that’s the case. And the reason for that
is if you put it off, you haven’t been
paying your fair share. So some people could say,
let’s just add 1% a year. And you can decide, but it’s
going to become more expensive for the day when you want. So they could replace it
with something like that. I think they’re going
to likely change the way the subsidies
are organized and the amount
that are available. Right now it’s done
through, basically, a government check
based on your income. They will want to change
it to a tax credit. Now, we could have a
lengthy conversation about why that’s different. But basically, it just
changes the way the subsidies. Now, by the way, it’s going to
take probably two-and-a-half to three years for the
IRS to be able to do that. And so if they
choose to do that, they’re going to have to keep
the existing plan in place and pay the subsidies. And that’s why they’re
going to have to pay for it. So that’s the way I think
the individual insurance thing plays out. They may allow insurance to
be sold across state lines. That would be a really
interesting experiment. I agree it’s not in and
of itself the solution. Then you have to
get to Medicaid. And that’s probably
on your list. But they have to deal with
Medicaid as part of this. And there are other sections. But in terms of what
you were raising, I think that’s the way
this ultimately shifts out. They do something to repeal it. They give themselves three to
four years for that to occur. They pass a series of
bills that will replace it, but they give themselves three
or four years for it to happen. They probably scale back
the amount of the subsidies and they change
the way it happens. But the system will
essentially continue to work through exchanges
and through employers going forward. So are you saying
they would scale back both the cost-sharing
subsidies and the tax credits? Because they all use the
refundable advancable tax credits just like we have
in the Affordable Care Act. But the question
isn’t the vehicle. It’s the amount that
they’ll allow to go out. OK. They think they’re too generous? Look, I think this is a great
place to bring something up. This isn’t being
driven by politics. This is being driven by
global economic forces that are requiring the United
States to deal with the fact that we have a $20 trillion
deficit, and that at some point we’re going to have
to deal with it. And so ultimately, these budget
issues are going to come back. Ultimately, you cannot
continue to do it the same way, because the world
will punish us– not with the military,
but with their economics. And so they are worried,
and rationally so, that if you just have
everything unlimited– they’ve got to find some limits. And I think they’ll
say, look, let’s continue to give these credits. But instead of having this many,
let’s kind of allow this many. And instead of subsidizing
this many people, let’s subsidize
this many people. And that’ll be the debate. I’m about to turn it
over to all of you. But I wanted to ask quickly, I
wanted to turn it to Democrats before I do, and ask you,
Nancy-Ann– and Governor, I know– and let me interject there. That I call her Nancy
and him Governor is not a sign of disrespect. I’ve known Nancy
for a long time, and her husband worked for
The New York Times as well. And when you’ve been governor,
Governor is like a nickname. [LAUGHTER] Don’t think of it as respect. It’s just a nickname. And I know you talk
to some Democrats, because you’re that
kind of a Republican. But what do the
Democrats do here? Do they just sit back
and watch the Republicans in their misery of their
legislative process, or do they try to have a
positive impact in shaping the ultimate outcome? Well, I don’t have
any inside knowledge into the Democratic caucus
and what they’re planning. But I think they’re very
concerned about stabilizing the marketplaces. And I think they
know from experience that getting 50 votes– everyone says, oh, they don’t
have to get 60 to repeal. It’s only 50. Well, getting 50
votes isn’t that easy. It wouldn’t be easy to get 50
votes in the Democratic caucus when we had 58 votes. It’s not that easy
to get 50 votes. So I don’t like the image
of them standing there as a group watching Republican
colleagues twist in the wind. But I don’t think
they’re going to help. I don’t think they’re
going to help with repeal. I don’t. No. And I wouldn’t expect
them to help with repeal. But if it’s done in a way that– well, I guess they
have to repeal if they’re keeping their word. What do you think? They’re going to do exactly
what the Republicans did. They’re going to start
looking to the next election. And they’ve got to come up
with the best things they can that’ll position them to try
and improve their position two years from now. And just like there were
a bunch of Republicans who would have liked to have found
a way to refine the Affordable Care Act and participated
in the debate, they’re probably not going to. Maybe it’ll be a bit different. I hope it is, because I
think there’s a chance here, if we begin to look at
this as a refinement and making the big changes
that need to be made. But history says they will do
what the Republicans did, which is start preparing
for the next election and trying to control
the news cycle. Yeah. Well, as you all
are clearly aware, you come to the middle
aisle to ask your questions. I hope the first three
people are students. And make sure there’s
a question mark at the end of your statement. Hi. My name is Matt Enloe and
I’m a second-year student at the law school. Some hospitals have just
begun implementation of some programs funded by
Affordable Care Act incentives. An obvious effect of the
repeal will be consumer price increases, but
surely there will be other unintended consequences. How would you expect
the cost that Trump is imposing to be distributed
both between individuals and institutions, and
what other effects do you predict from the fallout? Well, one thing that the
governor alluded to is this isn’t all happening in a vacuum. And we’re talking about a
$4 trillion industry here. So hospitals, all the
other providers, doctors– they’re at the table
right now demanding that if there is a
repeal and replace– and the hospitals broadly
supported health reform, because they saw people
coming to the hospital without coverage and they
wanted to have coverage– if there is a
repeal, the Congress must replace the funding
that they contributed towards paying for all of this. And so that’s just another
problem on the problem list that we’ve been talking about. How will they do that? How can they give the money
back to the hospitals? The hospitals argue that
if there’s no longer a plan to cover everyone, then
we need our money back for covering the
uninsured and covering the disproportionate
share of low-income people who come to our hospitals. And I think they have
a strong argument. So I don’t know how
it’ll be distributed, but I would be very surprised
if they pass some repeal or bill without giving that money back. And there’s more
where that came from. Most of that money is coming
from newly insured people. And as we talked
earlier, I think there is a widely
held aspiration in both parties for
there to continue to be access to affordable insurance. We’ve already had the
conversation about, at least my view, that they’ve made a
commitment that they’re not going to let 20 million
people find themselves without insurance. They would pay a
heavy political price. They’ve made a commitment
they’re not going to do that. I’ve already suggested I think
the way they’re ultimatley going to pay for it is by
delaying a lot of the income events. So I would argue that perhaps
the premise that we’re going to see hospitals
dramatically reduce is a process– and this happens
after most elections. When there’s a big
change in power, it’s like a nuclear
event occurs. And frankly, the best place
when a nuclear event happens is to lay in a ditch and let the
blast go over the top of you, and then look out and see
what’s going to happen. We’re still a bit in the
blast phase, where everybody is talking about
their worst fears and talking about the events
that will occur at the extreme. And I don’t think that any
of that’s going to occur. I think there’s
enough forces here that are going to keep rational
minds, if for no other reason, just because of their
political instincts. We will likely not see dramatic
reductions in hospital funding. Thank you. So Governor Leavitt,
you talked earlier about how we were in the middle
of a 40-year process in reforming our health care. And I was really impressed
to hear you say that, because normally you don’t hear
politicians talk about things taking the long-view like that. You normally hear about,
this is the one right here. Who else thinks like that? Who can we look to who’s in
office right now who is also trying to take that approach? Because somehow it seems
like people are just going, as you said,
from election cycle to election cycle. I think there are people in
both parties who think that way. But they are in a system that
requires accountability in two- or six-year segments,
or four-year segments. And so the system militates
a bit against that. I think it is necessary to view
this properly, to step back. It’s like Google Earth. If you could just
push that button and go out and
see these problems and then go back down
at the street level where you have to
fix them, being able to come out and see
it makes a big difference. At some point– we don’t
have time tonight– reconciling that 40 years
makes a lot of sense. And frankly, it
begins to dictate a lot of what you do to fix it. Hi I think this question
is mostly at the governor, but anyone can respond. I’m wondering, with the
upcoming congressional recess, a lot of Democratic
activists and organizers are talking about
putting a lot of pressure on town hall meetings
with representatives and really pushing Republicans
to change their stance. Already there are
Republicans talking about saying “repair” instead
of “repeal and replace,” and there seem to be
some fissures there. So I was just wondering if you
could comment on whether or not you think that these types of
efforts will have any impact. If you just lost an election
as profoundly as the Democrat party did, the smart thing to
do is to look, again, in history and say, who else experienced
this and what did they do, and how did it turn out? Well, it’s very easy to
look back to 2008 and 2010 and to see what the
Republicans did in 2010. They invented the repeal
and replace phrase. And they went to town meetings,
and they incited their base. And they got right in the face. And now, that’s exactly what the
Democrat party is organizing. So the roles have just replaced. The arguments remain the same. And it’s part of the way
the political process works. There’s a certain elegance in it
and a certain lack of elegance in it at the same time. We all get that. Thank you. Hi. Thanks for a very
interesting discussion. Ms. DeParle, early on you used
the phrase “a uniquely American solution,” which
is a phrase that’s often used in reference
to market-based solutions like the ACA. But I’m wondering
about Medicare, which is a program more
beloved by Americans than I think any other
government program currently in place, which is not
a market-based program and yet has been working. I’m talking about
traditional Medicare now, not the newfangled– Not Medicare Advantage. Right, not the
Advantage programs. It’s operated for
many years just fine without the insurance
companies being involved. And I’m wondering if that is
not also an American solution, and why that can’t be
extended to everyone. Well, Medicare is a
great American program. And I was privileged to lead
it for a number of years. And Governor Leavitt also
has the title “Secretary,” because he led it as well. And the Medicare Advantage part
of it is growing, by the way. So the choice of private plans
part of Medicare is growing. I do think, though, that it’s
different in that Medicare was set up to deal with a problem
where there was really nothing for seniors at that time. Seniors in this country didn’t
have access to anything, whereas what we
were trying to do was, hopefully, get bipartisan
support for a program that would build on what
we already had. We didn’t want to disrupt
employer arrangements. We didn’t want to disrupt the
market that already existed. We just wanted to strengthen
it, make it work better, get rid of some of the abuses,
the preexisting condition exclusions, and
the annual limits. So we were trying to work to
repair the existing system. As you’ll recall,
President Obama supported a public
plan operating alongside these private plans. We didn’t have the votes,
even in the Democratic caucus, at that time for such a plan. I think today that we might. So we’ll see if, after
the next two-year election cycle, whether things look
a little bit different. But there wasn’t the
support for doing something like Medicare for all
or a single-payer system back in 2009 or 2010. Again, it’s, as the governor
says, a 40-year process. So maybe we’ll see if
there is one later. I’m working on it. Could I just make a
brief comment on this? Because I think this
conversation on health care can be boiled down,
really, to one question. And that is, what role
do you want government to play in your life? And health care
becomes a huge symbol. And Medicare for
everyone plays out as we’re going to have the
government heavily involved in our health care. Oh, can I respond to that? Well, I’m talking–
you may not think that. But this conversation ultimately
does become about that question when it plays out in
electoral politics. I think it’s a mistaken idea. I think Medicare has
less government control– traditional Medicare–
than anything else that you have going
now, because people get to choose private
providers who are not controlled by the government. The government’s role
is merely to tax people and pay out money. Oh, no. No, I think– And set standards. Well, I think Nancy
and I would agree that we sat in offices
that control virtually every part of the system by
virtue of those regulations and payment rules. Whoever pays controls. Thanks. Hi. I have a question for you. In terms of Trump
has stated that he wants to work with
drug companies to lower prices of
prescription medications. In a marketplace like we have
and this type of scenario, how do you see that playing out? I mentioned just a
minute ago that I saw most of these
questions boiling down to what role do you
want the government to play. While I was secretary
of health, we were doing the
prescription drug benefit and there were a lot
of people who said, we just need to turn the power
of negotiating drug prices over to Medicare. Now, I know what that
plays out to mean. What it means is
that the government gets to decide which drugs
are available to people. In other words,
the government is going to decide which
ones are on the formulary. And the way these negotiations
take place in countries where the government does
is that they go to the drug manufacturer and they
say, if you want your drug to be on the market,
then you will give it to us at this price. Now, that may appeal
to a dealmaker, because they can leverage it. But if you’re talking
about the world of health, where drugs have different
effects on different people and people may choose,
then it becomes a question. How much control
on health do you want the government to have? I can argue that both sides,
but I think that is in fact the question. It’s a really tough question. Thank you. Thank you. With respect to health
care innovation, are the insurance companies
in an era of consolidation fit for purpose to do
competition and innovation if we’re coming down to just
a handful of organizations? There’s a big question about
whether we are coming down. As you know, both
of the two big– there’s been a few
smaller mergers, but the two big ones that are
on the table have been rejected. And they’re in court
right now trying to preserve those mergers. So we’ll see whether
they go through or not. But there’s a sense
in which, in order to do what we ask them to do
in the Affordable Care Act, they needed to get
bigger scale and they needed to be able to
bring new skills to bear to manage care in a way
that they had not before. So some of that
actually made some sense from the standpoint of
trying to do a better job of providing the benefits. And we also put requirements on
that they had to have a minimum medical loss ratio, in essence
saying you have to spend $0.80 of every premium dollar
on actual health care. So that means they needed
to tighten their belts and not spend so much
on administration. So again, that
leads to more scale. So a little bit like the other
question– this is really hard. I could argue it either way. I believe that we have laid
a foundation, not just really with insurance plans
but with providers, for getting them to work
more collaboratively with each other,
more team-based care, more working towards an outcome. And that’s been done through
incentives in the law and some penalties
in the law, and I think it’s working
relatively well and we probably should
take another run at the 2.0 version of that and
see what we can do with it. We haven’t had a chance in
this short amount of time to talk about what may be the
most profound change in health care since the widespread
adoption of health insurance. And that’s a change in the
way health care is paid for. Rather than paying
for it on a fee for every item or every
service, a lot of health care now is shifting
toward what’s referred to as value-based care, where
they’re being paid for in part at least by the results
that they produce. Now, that process of changing
the way it’s paid for is fundamentally changing the
role of insurance companies. And it’s beginning to blend
the traditional tension that’s existed between providers
of care and payers of care, because it brings
them both together to say, we are incentivized
to produce better health, not just more care. So the point I want to make
in response to your question is we’re going to see– no matter what occurs, in
the next five to 10 years– a dramatic change in the
way health care is paid for. And it will bring along
with it a blending of the roles of payers of
care and providers of care. And I think what we’re seeing
in this consolidation is the beginning stage of that on
this 40-year journey we’re on. Thank you. It’s a great
question, by the way. Hi. I’m a sophomore in the
college, and I just had a quick question
about Medicaid. Block granting the
Medicaid system has been an idea tossed
around by a couple of prominent Republicans. I think it was featured in
Speaker Ryan’s Better Way proposal. So two-part question,
the first being, do you see that as a serious
possibility going forward? And the second part being,
for states like Illinois that already really struggle
to pay for Medicaid, do you have any fears about that
leading to a loss of benefits, especially for medically
complex populations on Medicaid? Well, I have a short answer. I hope not. I hope we don’t move
towards block grants. And yes, I do think that it
could lead to not enough money to care for people with
medically complex conditions, because the governors
would be forced, probably. If you want to save money
through block grants, you’ve got to cut the amount. I know there’s another
argument, and I’ll let Governor Leavitt make it. I don’t actually know
your opinion of this. Well, I have actually been
through this debate three times, twice as governor and
once as secretary of health. And so I can give that block
grant speech as well as anybody on the planet. Governors just
dream of the moment when they could
just say, just leave the money on a stump
in the woods for us and we’ll take
care of everybody. But when you get down to
the actual reality of this, it’s a pretty
frightening proposition for a state who has had
the federal government as its partner so that
when unemployment spikes and things turn bad, then you’ve
got someone there with you. And the tradeoff is we
will take a sum of money and give it to you. Well, what the
federal government’s in this for is because it gives
them a limit to the amount they’re spending and it makes
their budget a lot easier. So I would suggest this
likely won’t happen, because in the final
analysis states begin to figure out
the reality of this. Block grants is
one of those repeal and replace phrases that’s used. Both parties have them. “Universal care”
is another of them. But here’s the second reason
I don’t think it’ll happen. The Republicans have
a bit of a problem in that 16 or so states– big states, states that
got Donald Trump elected president– expanded and have
Republican governors. Now, that’s a tough
one to say, hey, we’re going to take those away. I don’t think he’ll do that. Then you have a similar
number of states who were good
soldiers in the repeal and replace fight
and didn’t expand. So are you’re going to tell
them, so now we’re here, you just don’t get
any of the money. We’re just going to
give it to the people. That won’t happen. So they’re going to have to
find a way to resolve this. And I believe the
way they will resolve it is that they won’t roll
back Medicaid expansion. They’ll make some changes, but
it’ll still be there allowing those big states to continue. And then they’ll give the new
states a lot of flexibility. And they’ll use
the CMMI authority I talked about
earlier to give them all the authority they need. Now, they can’t just
expand it for everybody, because they’re also
trying to do $1 trillion worth of infrastructure
and so forth. So I believe what’s
going to happen is that they will essentially
reduce the overall– well, they’ll keep the amount
of money about the same but they’ll spread
it over more states. They’ll give more states
access to that money by giving them more authority. So I could go into more detail,
but I think the answer is no. And those are the two reasons
I don’t think they will. But I do think there
will be changes. Thank you. We’re on our last questions
here, so keep ’em short. In recent committee hearing
on repairing and working over Obamacare, one
of the witnesses was Governor
Beshear of Kentucky. And he was basically the poster
child of Obama really works. He said Kentucky was
terrible, and we brought it in and it was wonderful. And when asked
about block grants, he said, oh, that’s just a
way for the government to say, you’re going to be the
bad guy who has to cut it. So my question is– I was going to ask something
about glock grants too. But the question is, Governor
Beshear was like the poster child for Obamacare. It worked wonderfully. It improved the health
care of our state. We really needed it. It actually improved
our economy. And so when I asked why did
it work so well in Kentucky but everybody else is saying
Obamacare is a disaster, it’s terrible, his
answer was, well, because I wanted to
make it work and maybe those other governors
didn’t want to make it work. So could you each
comment on that? Because you’re saying
everything is politics. I think that’s true. And I think in
Kentucky, I had examples of people who didn’t
know that they were getting health care
through the Affordable Care Act, AKA Obamacare. They thought they were going
to the Kentucky Kynect. And the State Children’s
Health Insurance Program, which we both worked
on, was similar. When they thought it
was the state program, they liked it better. So some of it was branding. California is another example of
a state where they were all-in and it’s worked very well there. They have healthy markets. And I would also
suggest that things– I want to be clear. I don’t think
everything is politics. I think there’s reality,
and then there’s politics. [LAUGHTER] And politics is part of reality
that we have to deal with. But part of that
political reality is things are probably
not as good in Kentucky as the governor
makes them sound, and they’re probably not as
bad as the other side makes it sound. And when you get
down to reality, there are some problems,
and they need to be fixed. Hi. I’m a third-year in the college,
and I had a question, I guess, directed to both you. To what degree do you
think community rating has created distortions
in the insurance market? And what role do you think
community rating plays in repeal and replace
moving forward? Do we need to have a little
definition of community rating? OK, I will. Community rating
is when we decide we’re going to allow healthy
young people to pay more to make certain that
it’s affordable for less healthy older people. In other words, you’re taking
from one part of the pool to average it out. And they call that
community rating. And the dilemma here
is that the law created a fence, or a barrier,
and they said, you can’t charge more than
$3 for a sick elderly person more than you would for
a young healthy person. And so when you
do that, it means that the cost for the young
healthy person skyrockets. And that has created
serious distortion, and it’s one of
the things that has to be fixed in order for this
fragile individual market. And so one of the things
that’s being proposed is that you just expand
that to be five to one. Now, there’s
implications to that. It means that yes, the
young healthy people get lower premiums, but it means
that the less well older people have their premiums go up. And so it becomes a
matter of philosophy. What should our
philosophy be about people paying their fair share,
and society’s role? So it comes back
to what role should government play in our lives
defining so much of this. Right. And how much are you
willing to subsidize for the people who are sicker? And just to quibble
with one word, he said that it meant that
the premiums for young people had “skyrocketed.” When you actually
look at the numbers, yes, they’re higher
for someone like you. If you had been
paying for coverage, it might be 50% higher. But the premium number
itself would be quite low. Now, you wouldn’t like
paying $150 instead of $100. But when you look
at a senior who might be paying $500 or
$600 versus $1,000, to me that seems fair. But this is a
philosophical difference. And oftentimes, what the
solution turns out to be is, , well let’s not have
either of them pay it. We’ll just have the
government pay it. [LAUGHTER] And so a lot of
these decisions are, should we have rate
payers solve this problem or should we just let the
tax payers solve this? Somehow there’s this
amorphous thing out there. And that’s too often
been the solution. And it’s the reason we
end up in these situations where we have a big deficit. Thank you. Michael [INAUDIBLE]. Excellent presentation. I’m at the Kennedy Center,
and I’m a physician. I’m very concerned
about individuals with complex disability. There was never an
insurance market for them. Let me be explicit. The insurance market
never covered individuals who had Down syndrome, who
had CP, who had autism, who had intellectual disability. And the worst situation
in the world is to say, here’s your adult Medicaid. Good luck and how you negotiate
the adult health system. The assumption is made that
either the elderly are disabled and there is this very
small number of adults with complex conditions,
but the key assumption is what percentage of
adults are we talking about. And when you look at children’s
health and the complexity of whether it’s the autism
epidemic or the kids who survive leukemia or
things like that, they are much more higher than
the historical ratings work. And markets can work if I
have a 90% market share. Markets have never been set
up to cover 100% and all. And I was reminded of this–
and this is my question– Paul Ryan said on CNN,
we want the states to have this complex care
state-run marketplace for those with disabilities. And he makes the assumption
that it’s 8% of the population. He has no idea of
the basis of that, and it is so critically
important to get that right. At the same time, if I just live
in Trump land, in fairy tales– What is the question? –I can’t get the message out. How would you get
the message out, and how would you make sure
that all and choice in markets means all and choice
in true markets? I kind of got the impression
that was directed to me, so I’ll respond. [LAUGHTER] Thank you. Look, I think if
we had the ability to poll the entire population
of the United States and we were to ask them
a couple of questions– do you believe everyone ought
to have access to insurance– almost every hand would go up. If you said, do you think
the government ought to create a mechanism
to assure that people with complex disabilities
have insurance and the government ought
to be involved in that, I believe you would get
a profound response yes. I really do. I think that is the
American psyche. It’s our sense of compassion,
and it’s universal. Now, we said “the government.” Now we break into a new debate. Which government? And this is one that started
in 1787 at the Constitutional Convention, where there
were certain people who thought that a big national
government was just that ticket and then there are other
people who said, look, we have just spent a revolution
paying with our blood to get away from
that and we want to have the capacity of
our local governments to do those things. And we ended up with
a compromise called the United States of America. Now, there’s a lot
of people– and I happen to be one of
them– who believe that the people in state
legislatures passionately believe that those who have
disabilities and are complex ought to be taken care of. Now, there are people
who don’t believe you can count on states to do that. I don’t happen to
be one of them. But I do think it’s a
logical place for government. The big debate will
be which government. Thank you. [APPLAUSE] Governor, if you
lived in Illinois right now you might
have less confidence that the state can respond. [LAUGHTER] You know, there’s nothing
more refreshing than getting a retired health reform czar
and a retired politician together to talk candidly
about these issues. And more than that– because I know
them, and I suspect we’d get a candid conversation
under any circumstance– it is really, really refreshing
to hear a thoughtful discussion about a really complex
and important issue in a respectful way. And one of the things that’s
absent from our politics too often today is that. We’re never going to solve
our problems if we can’t restore that to our politics. So as much as you’ve
enlightened us, I so appreciate that
you’ve offered us light and not heat tonight. And for that, I
want to give you– [APPLAUSE] And I want to thank Jackie
for another excellent job of moderating. We’re not saying goodbye
to you yet, right? No, not quite yet. OK. And I’ll be back. But we loved having her
here these two weeks. So give her a big hand, as well. [APPLAUSE] And thank you, as always,
for your excellent questions. Have a great night.