Potential Midterm Election Implications for Health Care

Sarah Dash:                        Hello everyone, and welcome to The Alliance for Health Policy’s webinar on potential midterm election implications for health care. I am Sarah Dash, president and CEO of The Alliance for Health Policy and I will be facilitating today’s discussion. For those of you who are not familiar with The Alliance, we are a nonpartisan organization dedicated to advancing knowledge and understanding on health policy issues. Our mission is to educate the health policy community on the pressing issues, and we’re delighted to do that today. We’re excited to examine the role of health care in the upcoming elections, as well as the potential health policy implications for Congress, the administration, and state governments, and I’ll be introducing our speakers momentarily.

Sarah Dash:                        The Alliance for Health Policy gratefully acknowledges the National Institute for Health Care Management Foundation for supporting today’s webinar, which is part of the Beyond the Beltway: Health Webinars for Journalists series.

Sarah Dash:                        If you’re interested in joining the Twitter conversation today, please use the hashtag #allhealthlive and follow us @allhealthpolicy. Before we get started, I’d like to briefly orient you to the go to webinar platform, and read you some technical notes. First, we recommend increasing the volume on your speakers to get the best sound quality. Next, we’ve taken a screen shot of the attendee interface. You should see something that looks like this on your computer desktop in the upper right corner. You can click the orange arrow to minimize and maximize this menu.

Sarah Dash:                        You will be muted throughout the presentation, but you can ask questions by using the question panel to chat with us about any technical issues you may be experiencing, as well as to send in questions that you have for the panelists. And, we will collect your questions and address them throughout the broadcast.

Sarah Dash:                        Finally, all webinar materials are available to download in the handout section of your attendee interface. And you’ll find the materials that accompany this webinar on our website, allhealthpolicy.org, along with a recording of today’s webinar.

Sarah Dash:                        I’d like to introduce our esteemed panel of experts who are going to shed light on this important topic. Joining us today we have Joanne Kenen. Joanne Kenen is POLITICO Pro’s executive healthcare editor. Since arriving in Washington in 1994, she has focused on health policy and health politics, but her career, we are told, has had her cover everything from Haitian Hoodoo Festivals to US presidential campaigns. She jokes that sometimes it’s hard to tell the difference.

Sarah Dash:                        We will also have Jeanne Lambrew. Jeanne is a Senior Fellow at The Century Foundation. Her writing, research, and teaching focus on policies to improve health care access, affordability, and quality. Previously, Jeanne worked in the Obama administration, first as the Director of the Office of Health Reform at HHS, and then as Deputy Assistant to the President for Health Policy.

Sarah Dash:                        We have our third panelist here, who is Rodney Whitlock. Rodney is the Vice President of Health Policy at ML Strategies. He’s a veteran health policy professional with more than 20 years of experience working within the US Congress where he served as Health Policy Advisor and Acting Health Policy Director for Finance Committee Chairman Chuck Grassley of Iowa as well as earlier on the staff of former US representative Charlie Norwood of Georgia.

Sarah Dash:                        We are so grateful to have them here with us today to give their thoughts and best guesses on what is a very interesting election cycle.

Sarah Dash:                        Next, I’ll turn to our agenda for today. For those who have joined us for our previous webinars this year, we have formatted this one a little bit differently to allow for more of a free-flowing conversation. We’re going to dive right into a moderated discussion, and you can see that we’ve created a five-part framework that will bring us through some of the major components of this issue. Will spend about 14 minutes on each section. And, if you have questions, I will weave those into each section. And, then, finally, we will have time during this final thoughts section to answer any remaining audience questions, so please feel free to submit that at any time.

Sarah Dash:                        So with that, let’s go ahead and get started with today’s discussion. First, I want to focus on just an overview of the 2018 midterm elections, and what are some of the major trends. So let me turn to our panelists first and ask, how is this year different? Is it different? Is this a healthcare election and what are the trends that you’re watching? Joanne, you want to kick us off?

Joanne Kenen:                  2018 is definitely a healthcare election. Now, as everybody on this panel knows, and everybody in the audience knows, we have what I sometimes call the 24 second news cycle. We sort of lurch, as a country, from crisis to crisis and scandal to scandal, and I do not know what will be foremost on people’s minds when they actually go to vote in two weeks. Two weeks? Three weeks. But, we do know that there’s the consistent, that voters are coming back to is healthcare. That has shown up in all the polling for months, so whatever it is the other scandal of the day or concern of the day or outrage of the day or hysteria of the day, healthcare is sort of this rock on domestic policy. That’s what people are coming back to.

Joanne Kenen:                  And it’s not just something they care about. We are seeing it as a motivating factor. It’s the reason that’s going to get people to the polls.

Joanne Kenen:                  Now, a few months ago, if you asked me, what was the healthcare concern, I would’ve said costs, because we were seeing that. We were seeing that both in the polling data, and just as a human being if you had a conversation with anybody it would be about cost, specifically drug costs has come up in the poll, both Republicans and Democrats. But, one night last June a Texas courtroom, Attorney General Jeff Sessions filed the federal position on what had been a somewhat obscure and not-that-much-attention-getting lawsuit. And, when the government of the United States actually joined 20 Conservative states suing to overturn Obamacare yet again, it put pre-existing conditions squarely back in the spotlight.

Joanne Kenen:                  The Justice Department is not trying to strike down the entire law, but they do want the court to strike down the most popular parts of it, which some might think is not a great strategy for Republicans a few months before an election. Pre-existing conditions and some other related consumer protections, patient protections, are now at risk in this Texas courtroom. It’s a federal court, but it’s in Texas. It may take a year or two to play out in the court system. But, in terms of for the Democrats, it was a gift, because they can say pre-existing conditions are at risk. And, as we all know, pre-existing conditions, concern about pre-existing conditions, that is one of two issues, the other one being Medicaid, that stopped the Republicans from repealing Obamacare last year. So, every campaign in the country people are talking about pre-existing conditions.

Sarah Dash:                        Thanks, Joanne. Jeanne, you wanna jump in?

Jeanne Lambrew:            Sure. So, I’d like to build on that and talk about why. Why is pre-existing conditions such a hot topic in this election? And, I do think it goes back to last year, which, as a reminder, last year we saw the Republicans pledge to repeal and replace the Affordable Care Act, go from a political slogan to an imminent reality.

Jeanne Lambrew:            So, just looking at the House-passed bill, The Congressional Budget Office estimated that it will cause 23 million people to lose coverage by 2026. Results in destabilized markets in areas of the country where one-sixth of the population resides, and “overtime it will become more difficult for less healthy people, including people with pre-existing medical conditions, in those states to purchase insurance, because their premiums would continue to increase rapidly”.

Jeanne Lambrew:            So, everybody thought that the debate ended last fall, but look at the tick-tock. In October, the president issued executive order to look for alternatives to the ACA’s insurance reforms the same day he stopped payments for cost-sharing reduction subsidies. In December, Congress zeroed out the penalty for not having health insurance, the so-called Individual Responsibility Provision. In February, as Joanne mentioned, we saw this lawsuit that took the zeroing out of individual mandate penalty, and said, ‘Aha, the law is now UN-Constitutional, it’s no longer a tax, it’s a requirement for people to have coverage, and there’s no severability clause, the whole law should be struck down’. Indeed, in June, Department of Justice made an unprecedented decision to not defend the Constitutionality of the Affordable Care Act and strike down some of the pre-existing condition protections.

Jeanne Lambrew:            And, if that is all not proof enough, even the responses to the Department of Justice action from Republicans in Congress has been inadequate. There’s a non-binding Congressional resolution that got introduced in the House would basically have no effect. And, in the Senate, there’s a bill called the Tillis bill, which, in the words of the patient groups, would, in short, for people with pre-existing conditions not provide access to coverage.

Jeanne Lambrew:            So, all that means that I think the resonance of pre-existing conditions in the field, right now, is they want checks and balances. They want a Congress that’s gonna come in and slow down if not stop, prevent, and protect the protections that people care about in current law, but I also think is gonna create a primacy on trying to find common ground, ’cause people who get elected wanna do something, and flip it around. There’s a whole lot of Republicans that are up, especially in the Senate, in 2020, who also will wanna find common ground to move things forward.

Jeanne Lambrew:            I do think, should pre-existing conditions continue to play out the way we are thinking it would, we’ll see activity in the states. We already know there’s four states with ballot initiatives on the Medicaid expansion that we’ll know the outcome of in a couple weeks. We also see states like California that, with a Democratic governor, may be incented to act.

Jeanne Lambrew:            And, last but not least, I think kind of focus on pre-existing conditions [inaudible 00:10:10] we’ll talk about later, tee up the 2020 Presidential Election.

Sarah Dash:                        Thanks, Jeanne. Rodney?

Rodney Whitlock:            So, Republicans are in an extremely difficult position, here, in talking about pre-existing conditions, ’cause they’re not good at it. They have struggled mightily when confronted with the issue. Let’s roll the clock back to Jimmy Kimmel, and him opening his show one night talking about his son, Billy, who will have a pre-existing condition for the rest of his life. And, we all know that, and we react viscerally to that, ‘Well, that’s not right, we should be able to address that’.

Rodney Whitlock:            The problem is Republicans have struggled meeting a simple standard, the unfortunate standard for them has been if you’re not protecting pre-existing conditions the way that the Affordable Care Act does it, you are failing. And, so, talking about Senator Tillis’ bill, he says very openly on his website, “We’re not trying to replicate the ACA.” Therefore, he will necessarily fail.

Rodney Whitlock:            The problem Republicans struggle with in this whole conversation is taking it beyond that simplistic notion, that there’s only one way to do it, which is, of course, not true. There are different ways to getting at this question. How do you protect people with pre-existing conditions? How do you make sure that they have access to services, those services are affordable? But, everything I just said there all come with shades of gray, and you have to define terms. And, Republicans have struggled engaging in conversations where they’re trying to show ‘this is how we’re trying to get to that point’, and this is why this is such an effective issue for Democrats running against Republicans, because of the inability to message where you’re going to be on these types of things.

Joanne Kenen:                  I think that one of the ironies of polling over the last few years on the ACA is if you ask people, “Do you like the Affordable Care Act?”, Democrats say, “Yeah.”, and Republicans say, “Hell, no.” The intensity is much more on the Republican side. But, there was always a funny thing where if you asked people, and the Kaiser Family Foundation did tracking polls for months, many months, and can sort of see this quite consistently, if you ask people about provisions within the bill, not the bill anymore, the law, people who said they didn’t like the ACA actually liked a lot of what was in it.

Joanne Kenen:                  And, on the unpopular side, even Democrats never really liked the individual mandate very much. That was never, there was always just a sympathy for, ‘Should my government make me buy this?’. The individual mandate was never particularly popular. Republicans hated it and Democrats weren’t that crazy about it. The Democrats, obviously those that had the sophistication, understood why you needed it and how the market worked and why you needed this incentive to keep people in.

Joanne Kenen:                  Pre-ex is the opposite. Republicans really liked the pre-existing conditions, just that basic idea, without all the legal conditioning around it or circumstances. And, I think it’s basically just a basic sense of fairness that Americans feel if you’re a kid born with something, a heart defect like Jimmy Kimmel’s kid, or you get a disease and you’ve played by the rules and you’ve paid for your insurance, you should have protection. That’s why you have insurance. And, this has been a real sore point, as Rodney said, for the Republicans, ’cause there is sort of this basic gut sense of ‘there but for the grace of God, it could be me or my kid’ or ‘this just doesn’t feel right that if you’re sick you’re no longer protected’, and that’s why it has so much …

Joanne Kenen:                  There’s so many ads across the country, there’s so many politicians talking about their own pre-existing conditions, breast cancer for some of the women candidates, their children, heart disease, and Republicans trying to come back with ‘Yeah, it’s in my family, too. And, I understand … ‘ But, saying ‘I understand’ when you don’t have a policy that supports it is not a good place to be in. I mean, if some of those Republicans win, and some of them will, it won’t necessarily because they have a great pre-existing condition answer.

Sarah Dash:                        Let me spend just another minute on this, and try and tie a couple things together.

Sarah Dash:                        Rodney, you mentioned that there are different ways to get at pre-existing conditions. And, Jeanne, you mentioned that, perhaps, there might be some drive to find some common ground, particularly on this very potent issue.

Sarah Dash:                        Under the ACA, pre-existing conditions was part of kind of a three-legged stool that included the individual mandate and the subsidies.

Sarah Dash:                        What are some of the different policy options, and do they stack up in terms of numbers of people covered and protected? Could we get into that for another minute or two?

Rodney Whitlock:            Sure, I’ll jump in, and certainly my colleagues can correct me if they think I need to be corrected, here. But, effectively, pre-existing conditions and the way you structure protections for them is going to be a decision which basically says, ‘For people who do not have pre-existing conditions, how much and how will I ask them to cost subsidize the cost of people who have them?’ Because, an insurer will look at them and go, ‘I think that people with pre-existing conditions are going to be more expensive, I want to charge them more.’

Rodney Whitlock:            So, now, to stop that I’ve got to put a structure in place that in some way either subsidize or limit the ability to ferry. And, so, you start there. The ACA’s structure basically say, you cannot deny anyone who has pre-existing conditions, and then we limit the amount of variation between the healthiest to the sickest by I believe it’s three-to-one. Jeanne, correct me if I’m wrong. And, so, just note there’s a little extra something for you, there, but that’s about it. And, that’s structurally how it’s done.

Rodney Whitlock:            If are not in the ACA, if you are in, say, private insurance that’s governed under HIPPA, arguably, it’s a little more restrictive in that your community rate is effectively everyone pays the same, once you are, again, in an insured situation. People have talked about the idea of high-risk pools or the invisible high-risk pools, where you pull people out, look at them separately, and do it that way. But, we’re talking about policy areas where we are looking at different ways to do it. In politics, it’s either you are for it or you are against it, and that is how so much is being cast right now.

Jeanne Lambrew:            I may argue as much about being for or against than what you’re for, because, back up nearly a decade ago, the burden of proof for incoming president and the Democratic Congress was ‘How are you gonna do it?’, and ‘Is it enough? Is it too much?’. And, then, once regulation, I could argue that the challenge of making the law work and kind of getting up and going was because people were comparing it to an ideal. I still find my premiums expensive. I still get surprise bills. So, it’s not perfect with the old comparator.

Jeanne Lambrew:            Fast forward, Republicans are in charge, they’re in charge of the White House, they’re in charge of Congress, and they need to say what they’re for. I think we learned last year that [inaudible 00:17:25] groups, even Republican governors, weren’t really for the solution that they came up with. So, I think that’s the new pressure point. It’s not for or against, it’s what you’re for compared to what people have now. So, sure, the Affordable Care Act is far from perfect, but it is what people have. And, if you’re going to take away what they have, you have to prove that what you’re providing instead works. And, that, has been, I think, the challenge.

Joanne Kenen:                  I think lots of people are very confused. “Healthcare,” as the president has famously said, “is in fact complicated. It keeps us all employed.” But, people are blaming Obamacare for everything, right? That’s not how most people get their insurance. Most people get it through their job or a family member’s job, or, if you’re older, on Medicare. But, anything that went wrong in your healthcare, it became ‘blame it on Obamacare’. And, you still see it several years out. If you watch the Obamacare haters on Twitter, it’s ‘My drug went up, and it’s gotta be Obamacare’s fault.’ They have nothing to do with one another in many, many cases. But, because of this ongoing confusion about what it is and what it isn’t and what is it responsible and what is it not responsible for it has let people of both sides of the aisle keep irritating some of that. And, yet, it’s stabler than anyone thought it would be at this point.

Jeanne Lambrew:            And, just to add to that, the people who have pre-existing conditions know what they got. So, the community of people that have been discriminated against in the insurance industry are aware of it. People who have family members who had that experience are aware of it. So, again, go back to the fact that even, again, [inaudible 00:19:10]. 20 million people gained coverage. Tens of millions more gained these protections, and that is a constituency that wasn’t there even in five years.

Joanne Kenen:                  I mean, if you looked at the town halls last year, that’s what it was about. What slowed down, didn’t eventually prevent, eventually the House did pass its repeal bill, but it took a lot more political capital and a lot more months than they ever thought. And, those town halls last year were about pre-existing conditions, like 99% of what people were up there talking about was pre-existing conditions. And, people were frightened and angry that they were not going to get them.

Joanne Kenen:                  In the Senate some other dynamics came in, a lot of it was the governors and Medicaid and the fact that the bill did more than repeal the ACA part of Medicaid, it did a lot more like [inaudible 00:20:00] which is not on the table, right now, but it will be again, someday. But, pre-existing conditions, really, is what set fire to what we quote quote, you can’t see me here, but I’m making air quotes, “resistance” really sort of grew up around the fight over ACA.

Sarah Dash:                        So, this is a great discussion around pre-existing conditions, and before we kind of move off of the key topics that we’re looking at, in terms of the election three weeks from now, I just want to turn to Medicaid. As Jeanne mentioned, there are several states that have Medicaid ballot initiatives. What are you watching in terms of those Medicaid ballot initiatives? Are they the same across those states? And, what do you foresee, if anything, as far as what an incoming Congress might do around Medicaid?

Joanne Kenen:                  So, there are three Conservative states, Idaho, Utah, and Nebraska, that have not expanded the Medicaid under the ACA, and have ballot initiatives. And, right now, there’s not great polling on this. Right now, most people think they will pass. Now, it passed last year in Maine and Governor LaPage, he’s gonna go out fighting. Maine approved Medicaid in the first of these kinds of ballot initiatives by almost 60% and the governor had kept fighting, and that’s now in the courts and part of the governor’s race going forward. It’s on the ballot in Maine, they already won. I would expect, I think it’s quite likely that it passes in all these three states. How the next legislators and governors respond, we will see. I’m not sure they’ll fight it as, what’s the word for how fighting, I don’t know what word you would use for how Governor LaPage of Maine, it’s like his reason for living seems to be fighting Medicaid expansion. It may not be that.

Joanne Kenen:                  I mean, Idaho is a really, really interesting state, ’cause here’s this really Conservative, rock-solid, red state, and they’ve implemented the ACA. They run their own exchange, and they run it reasonably well. At the same time, they’re trying to tear it down. They had a proposal to basically get rid of it, which went too far, even for the HHS under President Trump. So, Idaho’s gonna be sort of fun to watch. We just had a reporter out there last week, in fact.

Joanne Kenen:                  So, I think that they’ll probably pass. I mean, we could be proven wrong. My gut feeling is they’ll pass. I’ve said things that are wrong, before. Montana’s a little different because they have expansion, and the ballot initiative, there, has to do with tobacco taxes in order to pay for ongoing Medicaid bills. And, I’m not sure if there’s any polling on that. You know that one?

Rodney Whitlock:            I do not.

Joanne Kenen:                  I think it’ll pass. I’m not that familiar with it.

Rodney Whitlock:            So, I think one of the things you are seeing, particularly in some of the more red states that did not expand, is perhaps a growing recognition that there’s all this money they could have been taking to this point, and, eventually, they may have to consider taking it.

Joanne Kenen:                  The rural hospitals sure want it.

Rodney Whitlock:            And the community health centers. I mean, there’s an argument to be made that you are turning down this money. Now, state legislatures where they have ballot initiatives have two choices: do it themselves and own the decision and responsibility for it or put it on the ballot and let the community at large make the decision for them. If you see it pass in three states on November 6th, I think you might see a bit of a wave, there, start to develop.

Jeanne Lambrew:            And, I would just add, beyond those three states this is a hot topic in the state of Georgia with the governor’s race. It’s come up in Kansas a fair amount. So, it is not just a ballot initiativecy, but it does cut on more traditional lines in those states.

Joanne Kenen:                  So, [inaudible 00:23:50] has close, and that was a totally Republican state, it was a Moderate Republican versus a more Conservative Republican fight. The Moderates did favor expansion and lost, so we’ll see what happens next year.

Sarah Dash:                        In terms of federal policy and the question of states leaving a lot of money on the table, the original Medicaid expansion, I believe, was due to … 100% [inaudible 00:24:12] has been phasing out over the last number of years, so what do you foresee, if anything, about a push at the federal level to get some of those latecomers to the game, you know, additional federal resources or is that completely off the table?

Jeanne Lambrew:            Sure, I mean, there has been a bill introduced by Senators Kaine and Warner, for obvious reasons, because Virginia was a late expansion state, that would, instead of having that 100% match attach to years like 2014/2015/2016, it would attach to the first year of expansion. That bill could potentially have more bipartisan support, because, at this moment in time, most of the states out there would be red states who would benefit from it. And, I do think there’s been a renewed thought about what the poor states could be getting from Congress that might be more amenable to it, so I think there could be some action there.

Sarah Dash:                        So, let’s turn now to our second kind of main topic, which is the post-election, or immediate post-election, or lame duck scenarios, and, understanding that there may be a number of different scenarios that might play out. We have a question from the audience, here, which is, “How concerned should we or how much concern should there be about Republicans trying to push through an ACA repeal, including Medicaid cuts or caps during a lame duck session, particularly if they lost the majority?” So, we’ll start off the next section with an audience question and go from there.

Rodney Whitlock:            I think that is a bit of a stretch to imagine. The House of Representatives and who is left and who is … The House has already passed the bill, the American Healthcare Act, would they be convinced to come back in and try again? The Senate, remember that you have was 52-48, it is now 51-49, meaning that you have to find a way to convince two Senators to change their vote. I continue to find that to be rather outlandish, and some Republicans, and I think you even see this in certain Republican races out there, at some point Republicans missed an opportunity to say ‘mission accomplished’. They didn’t have an aircraft carrier and a banner to do so, but once they repealed the individual mandate and implemented AHPs and STLDIs, Short-term Limited Duration Insurance plans and Association Health Plans, and begin to make the changes they did administratively, at a certain level they could have done more to declare victory to take them out of the situation where you’d be asking that question.

Joanne Kenen:                  Often, the reconciliation bills [inaudible 00:26:59]. They need 60, don’t they?

Rodney Whitlock:            No, you’re right, ’cause they use them on taxes.

Joanne Kenen:                  Right.

Rodney Whitlock:            But, they could use, we’re in the new budget year, you could do [crosstalk 00:27:10]. We’re talking really, really …

Jeanne Lambrew:            I will remind you that the current Congress that we’re still in did reconciliation instruction during a lame duck while President Obama was still in office. So, it is not …

Joanne Kenen:                  I mean, the two that would have to switch would be Susan Collins and Lisa Murkowski, and I don’t think any of us see either of them switching. I mean …

Jeanne Lambrew:            Sure, although, going back and looking at lame ducks, I think it’s an interesting period of time. I was around during what will be the most comparable one which is 2010, right, after there was Democratic control of the White House, Democratic control of Congress, and, then, there was a mid-term election, and what happened in the lame duck?

Jeanne Lambrew:            Interestingly, Pew Charitable Trust did an analysis of lame ducks and found that looking at 2010, 99 laws were passed and that represented nearly a third of the substantive output of the entire Congress. I mean, things happened, and can happen, especially if there’s a change, and there’s an outgoing Congress. Why would that be? Well, certainly the potential interest in some of the tax bills that we saw floating around the House on health savings accounts, poor mandate relief, maybe more extensions. I mean, that all adds up to $100 billion. But, that could be on the table.

Jeanne Lambrew:            Flip it around, there may be Democrats who’d wanna, would go along with them and get out of the way, because next year is gonna be a year where they’re both gonna be willing to put forward a positive image should they gain one of the chambers, and they may be interested in, again, cutting deals, there. We hear that there may be a big wall fight, which means there’s opportunity for, again, negotiations, and there could be policy put into that negotiation.

Jeanne Lambrew:            And, last but not least, this lame duck is gonna be full of announcements. So, this Texas case that we talked about, the judge is supposed to rule as soon as possible, the plaintiff’s asked for an injunction for January 1. Decision in that one. The short-term plan lawsuit decision sought by November 1. There’s a couple new rules that will come out probably next couple months which could also incent activity.

Rodney Whitlock:            The term of art that I know we used on The Hill to refer to lame ducks, and I think what you described there is called ‘clearing the decks’, and there are going to be opportunities to do things that you do under this current configuration that you know will be more difficult in the next. And, so, that will motivate a lot of what we see during that period. And, for those of us who would like to be home for good by Thanksgiving, oh, no, we are likely to be working on eggnog or maybe all anxiety.

Joanne Kenen:                  Right, but also they did finish, I mean unusually, they did finish the Labor-H, the health spending bill, and that’s done. So, the wall fight, they’re gonna fight over Trump’s border wall and other issues that are unresolved that I guess gets a December 7th deadline. It’s not that they can’t hang healthcare. If you want it, you can find a way on many things, but the main vehicle for putting a lot of the healthcare stuff is this Labor-H spending bill. And, that has, quite unusually, been addressed.

Jeanne Lambrew:            [crosstalk 00:30:18] and I will go back to another one of my fond lame duck memories was in the 2010 lame duck, as a reminder, we all stayed here and had a New Year’s Eve deal on doing continuing resolution on a whole bunch of policy. And, as a reminder, that was [inaudible 00:30:38] but we also had to repeal the CLASS Act and Appreciative Long-term Care Commission, and rescinding co-op funding in that particular round, so note that it doesn’t always match up.

Joanne Kenen:                  The other issue that is gonna probably come up in the lame duck is what’s called the ‘donut hole’, which on the budget bill, the budget bill a few months ago, there was a change that Pharma was very unhappy about, about making Pharma pay more toward it’s coverage gap on Medicare, it basically means that Pharma has to pay more to subsidize people’s drugs. And, Pharma won’t be able to get that rolled back entirely, but they are trying to get it made less, and they failed a few weeks ago when they tried on the Labor-H bill. We do expect that to come back and they’re not gonna give up on that. I mean, that’ll be, that’s their top priority, for the lame duck, and I think that’ll be one of the health issues that we do see. I don’t know how it’ll play out. I wouldn’t be surprised if they get some of what they’re seeking. They may not get all of it.

Sarah Dash:                        Rodney.

Rodney Whitlock:            So, I think one of the things that will make this a particularly fascinating lame duck is what I consider to be sort of the nexus of all of these decisions, and, if the trends, and currently the trends do certainly go in the direction of the House flipping, I think that the Senate still seems like a coin flip either way. And, I would point out, I don’t think I’m out on any particular radical ground, here, because if you look at ’94, ’98, ’02, ’06, ’10, and ’14, five of the last six mid-terms have ended up with one chamber flipping, so I’m not crazy out there suggesting a chamber could flip.

Rodney Whitlock:            If it does, think of the calculus it creates. And, so, for me, all of these flow through the office of one Chuck Schumer, because he has this opportunity to decide in a gatekeeper role what he wants to let go now versus what he wants to reserve on the table for 2019, because there’ll be certain legislation that, with a Democratic House of Representatives, has no chance of moving, that he may want to clear out, now. And, then, there may be things he would perfectly happy to wait to see there. And, this goes for every policy issue, not just those in our little parochial healthcare space. But, for example, you look at something like the health insurance tax …

Joanne Kenen:                  Big parochial healthcare space.

Rodney Whitlock:            … I’m sorry, our big parochial healthcare space. But, if you look at something like the Health Insurance Tax, the Device Tax, you look at CREATES, you look at the donut hole, I mean, the Senator from New York does have a lot of control because of legislative filibuster in determining when he wants to say ‘no’ and when he wants to let himself get rolled and they actually do something that is a compromise. And, I can’t begin to speak to how he will decide that calculus, but I’m pretty certain it rolls through his office.

Sarah Dash:                        Alright, well, anything else on the lame duck that we’ve missed?

Joanne Kenen:                  One thing that we probably haven’t thought of will pop up, ’cause it always does.

Sarah Dash:                        It’ll pop up.

Joanne Kenen:                  Somebody’ll say, “This is my last chance.”

Sarah Dash:                        Stock up on eggnog seems to be the message, here.

Sarah Dash:                        So, moving on to the 2019 agenda, and what might be on the docket, regardless of how the elections turn out, are there any must-pass bills, in terms of when it comes to healthcare for 2019.

Jeanne Lambrew:            So, Rodney and I were talking about this, so we can order this in different ways, but typically you look at the so-called extenders as the area where you’ll see must-pass activity. We, now, can rack up a good 10/12 policies that are effective through the end of 2019, and then stop, which means that Congress will need to act to restore, renew, prevent a cut, or whatever that particular activity is, and that tends to be an engine, a vehicle as they call it, for moving various and sundry policies.

Jeanne Lambrew:            The Medicaid disproportionate share hospital payment cut goes into effect in fiscal year 2020. We have the Community Health Center Fund that would, it’s additional preparation would end. Smaller policies like this [inaudible 00:35:18] which is about geographic adjustment and I can go on. Irrespective of their size and their scope, they tend to be, again, engines and drivers with mostly pluses, usually not minuses, meaning that they’re costers, which means the upcoming Congress is gonna have to think hard about when these happen and how they happen, and are they offset.

Rodney Whitlock:            So, from a legislative point of view, and having been in that role, Sarah, you’ve done this, as well, which is if I’m engaged in a conversation about these pieces, that is a very limited conversation. Now, paying for ’em, that’s certainly going to be a challenging conversation.

Rodney Whitlock:            But, I think what’s going to be interesting about ’19 will be the configuration in Congress. Do we have a Democratic House who needs to exert the election outcome by coming up with policies they want included in something like this? Where are you with the Senate?

Rodney Whitlock:            And, a place to think about that is, again, the 2007, after that election, after that slip, and we had a bill that we had to move through, the CHIP bill, the reauthorization of the Children’s Health Insurance Program where the Senate was able to work on a bipartisan basis a very limited bill, the House, now in Democratic hands, basically said, “Oh, hold my beer, I wanna do some work, here.” and went into all sorts of controversial spaces.

Rodney Whitlock:            And, to my friends who worked on that, please accept my apology for that metaphor. But, they went into all sorts of controversial spaces which had no prayer in the Senate in 2007. Will that be something we watch for in ’19?

Joanne Kenen:                  And, it’s not must-pass, but I think you may see … There’s some opportunities for some interesting developments that could occur with the House, assuming the House goes Democratic. Could the House Democrats work with President Trump on any of the drug pricing legislation? And, then, of course, there are all sorts of political calculations that are going into 2020.

Joanne Kenen:                  I mean, when President Trump, then Candidate Trump, started talking about drug prices, it surprised many of us. It really is something we associated with … Republican Senators weren’t talking about it, by and large. I mean, some of them have on certain on aspects, but the big message about drug prices was more of a Democratic issue. So that’ll be sort of interesting to watch. They’ll get tied up early on with larger politics about 2020 and Trump.

Jeanne Lambrew:            Although I may argue before the 2020 cycle begins in early …

Joanne Kenen:                  It’s started.

Jeanne Lambrew:            … it will be [inaudible 00:38:02]. There’s always that kind of six-week run through August recess of kind of that first year, either first year for president in the office or the mid-terms where there’s an opportunity, right?

Joanne Kenen:                  Yeah.

Jeanne Lambrew:            And, I think most people would have to say, going back to your earlier point when you ask people what they’re concerned about is costs, healthcare costs and drug prices are high up there, and it may be easier, in a way, to deliver on than many of the other items, especially given the president’s statements about drug prices, the secretary’s blueprint, and all this activity. So, I would argue that this must-pass legislation may be linked up with kind of these other more signal policies. And, obviously, there’s tons of policy in the drug space. It never is easy, but we’ve seen themes around promoting generics, trying to do more transparency. What do we do about high-cost drugs? Well, harder issue, but I wouldn’t be surprised if there’s not serious attention and maybe that strange, kind of, bedfellow handshake by the president with a potentially Democratic House and/or Senate.

Joanne Kenen:                  And, this is not a president that sticks to a topic, and, actually, drug price is something he has come back to over and over again since the final stages of his campaign, and he does seem to consider it a domestic priority. So, I don’t think you would necessarily have the whole 40-item blueprint enacted, but could some things happen? I mean, they’re already happening. Some are happening on a regulatory basis with the FDA. Can you see more sort of mid-level legislation on drug prices? I think you could see some. You’re not gonna get importation through without a lot of safety caveats or, I mean, it wouldn’t happen. Through government negotiation drug prices probably wouldn’t come through. Could there be, sort of, other that maybe be more technically difficult to explain in this setting, but could things happen that would address drug prices? Yes. The creates? bill is one of them.

Rodney Whitlock:            I think though, here I’ll be the skeptic, I do think that inasmuch as there are negotiations with the secretary, I could see activity here. I remain very skeptical that Democrats are going to be comfortable trying to work out anything that involves the president. And, just working off the metaphor, I think, that you suggested, I believe last September where we ended up was Democrats worked out a short-term deal with the president where the president, effectively, rolled the speaker and the majority leader to their side of the conversation, yet, a few months later, we had a shutdown occur largely over reaction aghast to his “shithole countries” remark, which then drove a lot of people away from the table with him. And, so, if he is integral to it, I’m far from convinced Democrats can participate.

Jeanne Lambrew:            And I will, just seeing the glass half full, argue that if, indeed, there is a, putting aside the president, if there’s a whole bunch of young, new Democrats in the House of Representatives, they don’t wanna go home empty handed. I mean, I think that you always have to remember that this is a largely different generation, a new generation, running on healthcare, so I do think that they may put producing results over traditional partisanship. But, we have two more that still think the opportunities next year are, maybe, bigger than I should. The opioid epidemic continues to drive attention in this country that are not traditionally partisan, and I do wonder if there couldn’t be another version of a bill, one that might be bigger, I think, than the one that just happened. Not in terms of the number of provisions, but in terms of the impact on larger coverage policy and spending. So, I wouldn’t be surprised if there’s a, kind of, more robust bill around opioid addiction. And, the sleeper would be could you pull off a health insurance marketplace stabilization bill? We know there’s bipartisan policy out there. There was a bill last year that could have succeeded as we all kind of know. Will that come back? I think that one might be harder for this president to sign into law, but [crosstalk 00:42:12] …

Joanne Kenen:                  They could also [crosstalk 00:42:11] that state by state through waivers. They don’t wanna do it. If they want to get to that … It was basically a way of shoring up the markets, I think. We’re talking about Murray-Alexander, right? They got pretty close a couple of times to, in the Senate at least, to some kind of deal that would stabilize the markets, and, in exchange, there were some other political compromises. Four or five states …

Jeanne Lambrew:            [crosstalk 00:42:37] to seven.

Joanne Kenen:                  Seven states have waivers, they’ve been successful, they have brought down prices, premiums in some of these states, so you could … And, it’s been blue and red states. Some of the states have surprised us that are not somehow Obamacare states, but they have decided to try to stabilize the market for their own citizens. If they can’t do this legislatively, and maybe they could, because if there’s a Democratic House, they’d go for it. Alexander-Murray reconfigure and get 60 votes in the Senate, maybe. It’s harder than it sounds on the surface, it’s a maybe, but there are also other ways that these problems can be addressed through [inaudible 00:43:20].

Rodney Whitlock:            Which, I think, you pivot to a really interesting question, which is: What is this administration gonna do with their regulatory authority in 2019 and ’20? Watching to see where they go with the use of the waiver authority. They’ve got a person actually in charge at CMMI, The Center for Medicare and Medicaid Innovation. What if they suddenly discover we like this idea of authority and watch us use it? That could be an utterly fascinating conversation for all of us in ’19.

Jeanne Lambrew:            [inaudible 00:43:53] These 1332 State Innovation Waivers, I mean, we saw a whole lot of activity or interest in it last year. There could be more activity there, for sure. I mean, to date it’s been used by states like New Jersey to get [inaudible 00:44:07] and use a restoration of the individual mandate penalty to pay for it, which is kind of an interesting twist. But, we’ll see what happens. But, again, states like California, there’s governors running on more aggressive agendas. Could they ever use 1332 and get it approved through this administration, question mark, right? But, I think it’s going to be an interesting year.

Joanne Kenen:                  And, then it has been a very active … I mean they could not get repealed through the Senate, they have certainly done a lot on a regulatory basis for HHS and CMS to advance that repeal agenda without actually repealing. The legislative piece, of course, will say they removed the mandate penalty, but introducing association health plans, introducing these short … Enlarging and extending these short-term plans because they’re now not so short. Reducing the outreach, a number of things. We will really see their impact or their lack of impact next year, because, first of all, the courts may stop some of them, we don’t know. States are taking steps to counter [inaudible 00:45:06] in some states. California has banned the short-term plans. And, of course, the exchanges have actually, they haven’t grown over the last few years, but they also haven’t imploded. And, even states like the state everyone was worried about, which was Tennessee, the poster child state for the death spiral, and it was gonna fall apart, I’m pretty sure their premiums went down for 2019. And, it’s much more stable. And, their new entrance is … Overall, next year, their premiums have dropped. The benchmark average is 2% drop, and that’s not true of every plan. It’s not true of every state. But, after almost 40% the year before and 20-something the year before that, I mean, it’s a big change. It is a stabler market despite the CSRs going away. It’s not a growing market, but it is not an imploding market. It’s a muddling through market. For the Democrats, muddling through is as good as they’re gonna get, right now. It didn’t implode. It didn’t get repealed. Their hope is they can build on in the future.

Jeanne Lambrew:            And the point estimate for Tennessee is the premiums are dropping by 26%.

Rodney Whitlock:            But, what’s interesting is where you just went, Joanne, is that’s totally inconsistent with the political narrative. Democrats are absolutely committed to saying ‘Republicans destroyed the Affordable Care Act, we have to go to Medicare for all’. And, Republicans are absolutely committed to saying ‘The Affordable Care Act is evil. It is wrong. We need to kill it.’ And, none of the above is actually happening. What you just described is …

Joanne Kenen:                  It’s muddling through.

Rodney Whitlock:            … actually reality.

Joanne Kenen:                  It’s muddling through. And, then, there’s a lot of new threats to the markets next year. We don’t really know how people are gonna respond to the mandate. And, that’s one of the issues before the court. Is the mandate as important in 2019 as it was in 2014. People thought that the elimination of CSRs was gonna be a complete disaster, and they figured out what’s called ‘Silver Loading’ which is a way of shifting the costs around and making everybody happy. It’s the technical explanation. So, I mean, there have been many times, on both sides, and both sides have been surprised. And, the Democrats end up with a narrative saying ‘It’s good, but not great, and we want to build on it’, or Republicans end up deciding they have to live with it and pull it to the right rather than, which is what some of the Centrist Republicans are saying, they wanna pull it to the right, they don’t wanna nuke it.

Jeanne Lambrew:            Before we go there, though, I do wanna go back to one other change that would happen should House or Senate change control, is oversight. When you talk about executive actions, I can say with lots of personal experience that aggressive litigation and oversight makes a difference. As a reminder, both the House and the Senate, Democrats have resolutions that would enable their legislative counsels to sue to defend the Affordable Care Act, including its pre-existing condition protections. There would be more scrutiny of what goes on in the administration large writ, which just in particular especially given some of the concerns about how are the exchanges operating, how much money is going on for outreach, what are you doing in your rulemaking? And, if nothing else, going back to my original ‘What are people looking for in this election?’ is a check and balance. And, I think that check and balance might be something fully palpable, in addition to being able to use hearings which is, again, something, Rodney, you’d know better than me, to set an agenda. So, I do think we should [inaudible 00:48:40]. That is a power that is gained with a majority. But, I think, should there be a change you will see a lot more healthcare [inaudible 00:48:48].

Joanne Kenen:                  And, all these new forces that are surrounding the markets, we don’t know how it’ll turn out. 2019 could turn out to be a disastrous year. The AHPs and the short-term plans, they’ve become extremely positive, but the reality is that the people in the exchanges are mostly subsidized, not 100%. And, the problem, still, is that people who don’t have subsidies have a whole lot of trouble paying for health insurance. If you don’t get a subsidy and you’re in the individual market, it costs a lot of money. And, that is something that has to be addressed. It’s a larger issue back to where we started about the cost of care. Not just the costs of your premiums, but the cost of care. If these new plans, these short-term plans and stuff … It’s the currently uninsured that will go for those ’cause they can’t afford an exchange plan. Then you can have these parallel … It’s not the ideal, wonderful diverse market that the designers of the ACA wanted, but it lets you keep muddling.

Sarah Dash:                        Let’s go, before we turn to 2020 and even more looking into the crystal ball, we did have another audience question. Again, kind of going back to the cost question which was whether any of you have any thoughts on whether there might be a Congressional or a regulatory agenda focusing around healthcare consolidation in the the industry, particularly with so many blockbuster mergers and acquisitions taking place. What do you foresee there? How will that affect consumers, if at all?

Joanne Kenen:                  We’re seeing it in the state. Basically, most of the hospital mergers, most, not 100%, have gone through under both administrations in recent years. The bid insurance mergers, a year or two years ago, they were halted. But, then, we have these new different kind of healthcare animals which is the PBMs, not the pharmaceutical managers, but the retail drug and the pharmacy benefit managers merging with insurers. So, CVS and Express Scripts, and there’s a whole new, I always forget which one matched with which. It’s Aetna and CVS, right?

Rodney Whitlock:            Yeah, and Cigna and ESI.

Joanne Kenen:                  So, those are really new, and there are people skeptical. I mean, the defenders say that if the economy is scaled, it will bring down prices. And, other people said consolodation is just making prices go up. We’re still struggling with the belief that better integration of care, and ACOs and other ways of a more coordinated approach should, in theory, save money. But, if it just becomes a monopoly, then you have two counteravailing pressures. I don’t think they’re gonna stop the mergers, federally, but California’s a big … There’s a case that everybody’s watching which against Sutter which is a dominant chain in Northern California. The prices in Northern California, premiums and healthcare costs, are much, much higher than Southern California. The hospital industry, ’cause I was there last week, so I can tell you fresh, they say it’s all because of labor costs and unions and wages and being higher in Norther California, but there’s some economists who’ve looked at that and factored that in and said, ‘Nope, it’s consolodation.’. So, there’s a big, sort of, landmark lawsuit on that.

Sarah Dash:                        And, let me ask you, and if Rodney or Jeanne want to weigh in, but does this issue hinge on the outcome of election or is this more, as you said, Joanne, it’s in the states, it’s with the state AGs, it’s with the federal regulatory agencies.

Joanne Kenen:                  The FTC hasn’t been that aggressive in the past on hospital mergers.

Rodney Whitlock:            If you’re somebody who’s a legislative staffer, and you want to follow an area, one of the things that you have to think about beforehand, assuming you do this job well: Where am I going? What am I gonna do? And, I think one of the things that Congress struggles with, and why I think you see a limited amount of interest in this subject for Congress, compared to other areas where they’ve been, is the problem with the answer to that question: What am I gonna do, get in the way-back machine and pull out my Teddy Roosevelt and go break up trusts, I mean, exactly what is it I’m gonna do once I start down that road? I think people on The Hill, when they talk about this subject, it’s almost as if they’re like, ‘Well, okay, but what am I gonna do about it?’.

Joanne Kenen:                  So, the [inaudible 00:53:08], if you can’t go back to Teddy Roosevelt, I mean, is California really gonna try to break up Sutter, or are they going to try to change behaviors and outlaw certain kinds of contracting practices and gag rules and other things that have created a lack of transparency and more market power for these hospitals? We, actually, a bunch of reporters were there last week and talked to the Attorney General Becerra, and did not get a totally clear answer on this, but I came away with the impression that it was a behavior change rather than a trustbuster.

Jeanne Lambrew:            Sure. I will say, though, this has, I think, contributed to some of the discussion about public plans and Medicare for More/Medicare for All, because there’s a view that if, indeed, this is unstoppable and is resulting in higher prices and, look, I think, nobody’s yet refuted the late, great [inaudible 00:54:02], if the price is too good, that’s why your healthcare costs are too high in this country. There is, and we’ve seen this in … Go back to California, they have the surprise out of network emergency bill provision, or, excuse me, law, that would cap what health plans pay to out of network providers for certain services at a multiple of Medicare, using Medicare rates in private insurance as a backstop, and I think some of what we’re seeing now with concerns about consolodation as well as what’s going on in rural areas. We have monopolies in rural areas, too. And, prices are really high in many places, so I think those two things are driving some of the discussion about looking more at what public plans do and how they can address [inaudible 00:54:46].

Sarah Dash:                        Let’s take this opportunity to, now, move on to 2020 and, perhaps, well, I’m not gonna even say beyond, so let’s just kind of look ahead at 2020 and what are some of the bigger picture themes that might emerge. As we’ve said, we’re kind of already in the presidential election cycle. I don’t know if it’s officially now or the day after election day, but how might the current mid-term elections or the 2019 agenda kind of lead forward into what kind of conversations might take place about healthcare in 2020.

Rodney Whitlock:            Exactly where Jeanne just went, no question about it. We’re going to have a, it will start in ’20 and it may bleed into ’21, which is a debate over a very simple question, which is: ‘If you think costs are a problem, if you think it’s the prices, we can do something about that. We can, simply, control them. We’re the government, watch us do it. You don’t think we can? Watch us.’. And, Medicare for All, Medicaid for All, single-payer, all payer rate setting, reference pricing, they’re all going in the same direction, which is: ‘If you have a problem with what the prices are in Northern California, here, watch me, I’ll wave my hands together, snap my fingers twice, and three times, and, look at that, I just set all the prices. Now, let’s have at it.’.

Joanne Kenen:                  And, yet, single-payer failed in California, probably, because they couldn’t figure out the economics of it.

Jeanne Lambrew:            Yeah, because you conflated three or four things at once. This is what happens in this debate. This is a debate that often gets jumbled in the terms. Single-care can be administered 100% through private insurers paying rates that they negotiate with plans, right?

Sarah Dash:                        Sort of what Netherlands …

Jeanne Lambrew:            Exactly.

Rodney Whitlock:            Yeah.

Jeanne Lambrew:            And, vice versa. You could have an entirely privately run system that has some sort of combination of regulatory set prices and negotiated prices, which is Medicare Advantage. So, I think we have to begin to parse out this debate, and figure out what’s going on. And, I think this is gonna be a question of what problem are we trying to solve, right? And, I do think that we’ll have this debate in a very rigorous way, I think, in the next couple years. But, going back to where we sit, today, we’re talking about at mid-terms, we’re talking about people concerned about losing,[inaudible 00:57:14], those people with employer-based coverage are a little bit worried about their deductibles going up, their premiums being high. What can policy makers do about that, and what are the solutions? So, public plans have a spectrum from, like the California policy, where they’re using Medicare rates, to Medicare for All is the other extreme, but compared to what? Right? ‘Cause, again, the Republicans have to come up with their plan, and, last time I checked, the Graham-Cassidy type of approach, which is take all the ACA funding for coverage, put it into a block grant, send it to states and devolve decision making to states is your compare and contrast. So, I do think, when we’re talking about this, there’s one side that’s gonna be choosing interventions and problems focus on Medicare and what is good about, and I think the other side is gonna be talking about more fundamental what is the role of government.

Rodney Whitlock:            What problem do you think that they are trying to solve? I mean, is it access, or is it cost?

Jeanne Lambrew:            I think you hear different people saying different things. You listen to Senators Bennet and Kaine, who sponsored his Medicare-X bill, it’s to rule America. It would go into areas where there’s either provider shortage, or only one insurance company in the individual small group market. And, in those circumstances, the public plan would offer, where there’s no other choices, and, then, over time it would face an ‘that’s their problem’. Keep going, look at the Shaheen Surprise bill legislation that just got introduced, it’s using a Medicare rate cap on what plans would pay when you have some out of network provider for what is in network service, as a way to avoid balanced billing, so that’s a consumer problem. So, different problems, a different bill.

Rodney Whitlock:            But, are the core problems still price in every spot.

Jeanne Lambrew:            No, market failure is what the Kaine-Bennet bill is about. What is the alternative to getting affordable insurance in rural Colorado?

Rodney Whitlock:            What’s the issue with the affordability? Is it the price?

Jeanne Lambrew:            Prices and premiums, yes, in rural Colorado, so [crosstalk 00:59:18]

Rodney Whitlock:            Prices drive the premiums. [crosstalk 00:59:21] always coming back to price.

Jeanne Lambrew:            And, the answer is, for Republicans?

Rodney Whitlock:            Oh, listen, I’ve watched Republicans in six years saying only three words to every problem: repeal and replace. If you think that they necessarily have to have actual solutions comparatively, I don’t think that’s at all necessary.

Jeanne Lambrew:            Which I think is what this debate is going to be about. Going into 2020, maybe it is preserving and proving status quo, and I don’t wanna dismiss that, because it’s a long way between here and there. And, it could be that we’re hearing our extremes talking about these big ideas to get at the fundamentals of the system. But, I think we have to have a contrast of ideas, and that’s what I’m hoping for. And, that’s why I’m glad that you’re doing [crosstalk 01:00:05], because we need to have an informed debate.

Sarah Dash:                        And, we will do it early and often. And, as you all are speaking, I’m just wondering, are we, again, gonna kind of find ourselves in the conundrum in which the voters and the public is really concerned about cost, really concerned about prices, and, then, we start getting into that conversation. And, for some people, the answer is resetting price control, that kind of thing. And, then, for others, it’s market-based, market-driven solutions. And, then we kind of get into a bit of a debate, and end up [crosstalk 01:00:42] and it’s not really any further

Joanne Kenen:                  … and it’s really easy to confuse, and it’s really easy to obfuscate. I mean, I think we all saw the president’s op-ed the other day, that the Democrats want, I call it Venezuelacare, that the Democrats wanted to turn the United States into a Venezuelan healthcare system. I don’t think you can find one Democrat anywhere in the country who regards Venezuela as their model for healthcare. But, it’s gonna be something that they can … I mean, people have been pounding government control, that’s why it took a hundred years to pass the ACA. Americans are receptive to the message that you don’t want government to control your healthcare even though it’s already controlled [crosstalk 01:01:27]

Sarah Dash:                        Unless you have Medicare. Unless you have a Medicare card, right.

Joanne Kenen:                  Right. But, I mean, that’s been a very effective political tool going back to the ’30s, and we are gonna hear a lot about it in the next few years. And, there are, probably, some things you could choose to address in a bipartisan basis, but we’re not in a very bipartisan mood in the country, except for opioids.

Rodney Whitlock:            Jeanne, I’m not necessarily telling you I’m going to enjoy that conversation, I’m just telling you I feel like it’s coming. And, that I would much rather have the thoughtful conversations towards where you’re talking about, Okay, let’s look at where we are, muddling along as it is, and say, ‘Okay, where can we get to something that we could agree upon?’ is a pathway forward.

Joanne Kenen:                  We’re gonna have Venezuelacare versus Muddlecare.

Sarah Dash:                        Well let me ask, someone asked, going back to the surprise billing, if that would be a place of common ground. But, I wonder if the three of you could comment on that as well as are the American voters in a place, now, where they just want solutions, and are they ready for a different kind of conversation, ’cause it seems to me that what they are receptive to is what’s gonna [crosstalk 01:02:38]?

Joanne Kenen:                  Yes and no. I think there’s part of our country that is tired and probably frightened by some of the divisiveness we have right now, but we’re also in a really partisan state. So, if you look at what’s driving voters, we don’t have a very healthy center in the country right now. And, for some things, you probably need to start with center and work from there. Not necessarily everything, there are some things that people are always gonna feel really intensely about on not in the center. But, right now, we have a country that’s really, really angry, divided. There’s been some violence. I don’t think people feel good about where we are, but I also don’t see anybody pushing people to have sensible, calm policy discussions about the best way, probably. And, there are exceptions. They did manage to do opioids. You can say it didn’t go far enough. You can say it didn’t have enough money. You can say we need more. But, they did a bipartisan opioid bill that was actually a public health bill, not primarily a law enforcement bill. I mean, it did set the country on a direction that, I think, everybody around this table would think is a useful direction to be going in.

Jeanne Lambrew:            And, I wonder if we’re not going to be seeing more interesting activity at the state level, which has often been … I mean, I don’t think there’s the ability to take what works in one state and export it to different states, but it at least serves as [inaudible 01:04:03] symbolic proof of concept for different ideas. And, I’m just wondering if we could be having this major debate, again, in two years, which as somebody who’s done health reform for most of my adult life, I feel a little health reform fatigue. But, putting that aside, we might have a debate. But, we also might, instead, be focusing on smaller big reforms. Again, like the idea of using Medicare rates and these surprise bills, which, again, Bill Cassidy from Louisiana is working with Democrats [crosstalk 01:04:38] and they’re not using the word ‘Medicare’, I wanna be clear, but they’re beginning to try and figure out what we could be doing in this space. So, it could be these types of bills, or you start seeing a lot more state experimentation.

Rodney Whitlock:            So, I’m gonna do something a little radical, here, and defend surprise bills. Not fully and completely, but just to make the case that providers have contracts. They have contracts with insurers who have people who are in-network and then there will be people who are out-of-network. And, the system is structured in that relationship for you to have a lower rate for people in-network and a higher rate for people out-of-network. I mean, that is sort of a fundamental structure, here. Now, if we want to sit around and agree that if you’re charging somebody who is out-of-network 3,000x what you’re charging somebody in-network, I might find that offensive. I think we might even come to an agreement, there. But, once you say, ‘Okay, I’m gonna start at the dial, and I’m gonna start turning that dial’, eventually, you are going to get to a point where use of that dial could be problematic for the entire structure.

Jeanne Lambrew:            I don’t disagree. I think that the policy [crosstalk 01:05:44]

Joanne Kenen:                  If you surely blow up the network system and those prices just rise and they get shifted to everybody and we all … But, I think the other thing about this surprise bill is that people, and this is not partisan, Republicans and Democrats both get surprise bills, as a consumer it’s really hard to know if you’re setting yourself up. I mean, either you get misinformation or you’re unconscious, or it’s a dire emergency. I mean, there are fairly sophisticated healthcare consumers, including myself, I only didn’t get one because I was lucky. I asked every correct question, and I couldn’t get the information I needed. In my case, they were small and we ended up in-network, but only because we were lucky. I couldn’t get the answers. I knew what questions to ask and I couldn’t get the answers. Even lying there with the IV in, they couldn’t tell me if the anesthesiologist … At that point, I still couldn’t get the answer. I got the answer when the bill came.

Sarah Dash:                        And, perhaps it’s some of that consumer frustration, that by conjecture, that’s driving some of the passion around issues like single-payer, because perhaps it’s more of a passion for simplicity in the system, my own personal opinion.

Sarah Dash:                        Let me, we have just under ten minutes left, and we have one more audience question that I wanna ask before we wrap it up, which is a profit question for all of you, which is: Wouldn’t any major reforms, anything regarding Medicare, etc., still need 60 votes in the Senate, which is unlikely for either party in 2019 or even subsequently? And, the questioner points out that the ACA only squeaked through when there were 60 Democrats in the Senate. So, thoughts, conjectures on that? All of these ideas being what they are, what are the odds of actually passing anything?

Joanne Kenen:                  Depends on what it is. I mean, can you do surprise bill legislation? You could get 60 votes if you got the right balance, there. I mean, there are technical issues related to what Rodney was talking about. You don’t want to blow up the system, but you don’t want consumers going home with a $200,000 bill because they had a heart attack and the ambulance took ’em down the street instead of across town where they were in-network, right? We don’t want that to happen.

Joanne Kenen:                  Are you gonna totally redo Medicare without 60 votes? No. By definition, what you can 60 votes for is something that is bipartisan and that’ll probably be incremental. If you go the reconciliation route, if, in fact, we have a Democratic House and a Republican Senate, which … Predicting anything is crazy right now, because everybody is always wrong about everything. If that’s the scenario, if we have a Democratic House and a Republican Senate, again, it’s gonna have to be bipartisan, you’re not gonna get things through the Senate. So, if you have reconciliation in a Republican Senate that the Democratic House won’t go for. If anything happens under that scenario, it’s gonna be more incremental, smaller. I mean, we do have a Medicare trust fund problem. Six years from now, there have been bipartisan, there’s never been a century-long bipartisan fix, but there have been 10 or 15 year fixes over time. That would have to be bipartisan. I don’t see what the fix is. I don’t see anyone talking about it. I don’t see it happening, but, in the next couple years, they’re gonna have to talk about it. So, incremental steps can be bipartisan, major, dramatic ones, unless we’re way wrong about what’s happening this election, and one party ends up with this huge, overwhelming majority in both houses.

Rodney Whitlock:            I’m gonna say something that I hate saying, because I hate believing it. I don’t like that I’m about to say this. But, I’m pivoting off of what Joanne said a few moments ago about the lack of a center in this country. I mean, nobody tunes in to watch the ranting of a raging moderate, anywhere. That’s not the way our world works. If 2021 …

Joanne Kenen:                  Well, I can think of one.

Sarah Dash:                        Two. In this room.

Rodney Whitlock:            If 2021 results in a unified government with the same party holding the House, Senate and White House, I fear for the future of the legislative filibuster. I don’t think that an America that elects a sweep in ’21 will hear that the minority gets to stop them in ’21.

Jeanne Lambrew:            I’m going back to my optimism to say …

Rodney Whitlock:            I’m glass half full of battery acid.

Jeanne Lambrew:            And it’s only, really it’s only because I tried very hard to learn from my experience in health policy in the past. And, it wasn’t that long ago, I think it was 2015, when Republicans took over the senate that the Republican Congress sent President Obama the macro legislation and he signed it. And, it was not uncontroversial, granted it got around some of the hard problems by the way they dealt with the budget offsets which was …

Rodney Whitlock:            A $350 billion dollar Mulligan they took?

Jeanne Lambrew:            [inaudible 01:10:50] the $1.5 trillion tax cut that got taken, so, let’s cast our stones, here. But, just as a signal, in the midst of things policy can happen without a lot of public attention when there is good, hard work, agreement on goals. There is an ability to work with each other, which I have to hope can be restored. And, again, we have recent experiences. Not a big bill [crosstalk 01:11:16]

Sarah Dash:                        NIH.

Joanne Kenen:                  Call the NIH bill, I wanna read it and look over it.

Jeanne Lambrew:            [inaudible 01:11:25] a opioid cure bill, there you go. [inaudible 01:11:29] and I think one never knows.

Sarah Dash:                        Well, on that note, we really appreciate all of you taking your time and to all of our viewers spending some time with us this afternoon. Unfortunately, that is all we have time for for today’s webinar, but we hope that our audience will take time to complete the brief evaluations survey that you will receive immediately after the broadcast ends, as well as my email later today. I can’t ask for a round of applause, but, again, thank you to our panelists. If you do have thoughts on our broader programming The Alliance for Health Reform we would appreciate that as well. And, we have a broader audience assessment and that’s on our website at allhealthpolicy.org. So, finally, if you are in the DC area, we hope that you can join us, in person, for our next event, which will be on Friday, October 19, and it will be an in-person briefing which will explore the landscape of diverse coverage policies and benefit designs that states are pursuing within their Medicaid programs, and discuss the impact of these policies on beneficiaries and the healthcare delivery system. So, with that, again, thank you to Joanne Kenen, Rodney Whitlock, and Jeanne Lambrew for joining us this afternoon. Thanks to the National Institute for Healthcare Management Foundation for supporting this webinar series. And, have a good afternoon.