Transcripts For CSPAN Health 20240704

Tuesday. Yesterday, both the house and Senate Approved a shortterm government funding bill to avert a federal shutdown tonight. It makes next friday the new deadline for congress to Reach Agreement on federal spending or a partial Government Shutdown will take place. Watch live coverage of the house brian has a longer history, he was the point person for Health Policy change if not reform. Different opinions on that in the Trump White House and prior history on the senate side and on the house side after the enactment of the a. C. A. He has been be a spring board and Research Assistant and the rest is history. He has been able to overcome it. John was over there in the senate which is the important ingredient and health, education and Labor Committee with senator kennedy and wrote a book about it. 12, 13 years ago. John was a practicing politician and knew how to run for office and get votes on occasion. Were all recovering in different ways. So john will be our last speaker. I may have some additional thoughts at the back end and then question and answer. Kind of our basic format for today. Why we are doing it more or less, the speakers and then the format. I have a lot of shutin time. I was streaming a lot, you have to have a tight if you are going to Health Policy comedy. Thats my lesson there. And lets see what we got. Hopefully triggering rounds of deeper discussion and real analysis. First why look backward to move forward . We have things about that history. Those who do not remember the past are condemned to repeat it. Ok, we can start with that one and karl marx. And mark twain, he said that history does not repeat itself but does rhyme and final comment, donald trump, history doesnt repeat just retweets. Now the fact is we dont know much about history in the same cook sense or in the witness movie. We dont know much about history or biology or in the science book. A bit of amnesia of what we remember selectively and different stories of what it is but other lessons we didnt quite learn and we will try to do in looking back a bit. There is science and biology. The waves of Health Policy reform and its not going to be a while now until 2038, the cicadas come out and then they go away. And there are iterations that are frequent and something remains afterwards. There is a convergence of two different strands coming in other parts in illinois and southeast. But we are going to miss that. Its like taylor swift, she isnt coming to d. C. This time around. If you want to do as i proposal hissed you from the science. Ill just do laws of motion. And the idea here is we have motion where everything is going to fly apart and then motion it terms it pulling back in. And things are going to be chaotic and what cements things together is a most powerful than compound interest. That is how we hold things together. And looks like there are going to be wild swings but we dont go off the rail. This might be a little extreme. I decided not to use the holy grail. So lets go back to the 1940s, only dramatic move yeoh in kings row, the local town physician cut off his legs to spite him because he was dating the wrong girl. There was a thing that you cant use where he wakes up in the bed at home and exclaims where is the rest of me because he is missing both his legs. Some people might say where is the rest of me and maybe were cut back a little bit. I may be going strong on that part. I recommend the movie from 1942. You have to remember we are going to hear a lot of cliches, this is the line from bull duham. You have to know. And we have cleche as. And there are a lot of acronyms. Carve off a little bit. If you want to get down to the stuff that is a little more lasting. Running a little fast here. I have to have a little bit of content. Thats why i was slowing down for just a split second. 9a. C. A. Beyond age, the reference to where is the cake, sports fans, in 2005 they are having a celebration down at the Capital Center and two wizards and get ready for the big celebration wheres the cake. This is the same thing for these afters sears. Anniversaries. Looking at the a. C. A. , memories are kind of selective we do then versus now. Not everything that was assumed actually came into place. But the magical thing is it doesnt matter if you damage or cut off a couple of those legs on the threelegged stool as long as you have the magic of money and subsidies. When you have a rough crash landing, that money works as a wonderful flotation device. There are a lot of tougher claims made about the a. C. A. In terms of what it delivered. Some things happened. We can explain it in many ways but leave it for the audience here or our speakers to discuss, but the main thing is keeping business in business and business did ok under the a. C. A. Some of the force fields in terms of the basic laws in motion. If you think it is going to happen, turns out not to be the case. People werent predicting opioids, covid pandemic, changes this eligible rules for medicaid, all the various regulation changes. So what is the front end sale saying it is going to on work like this. You are in a different world because what you passed isnt what you implemented. That is part of the larger message front end sale and what laws are you going to have or life is like a box of chocolates and never know what you are going to get it and a. C. A. Fog of the war things dont work the same way after the first shot of battle goes on. I have gone on long enough. Lets go to our opening speaker who will do ghost hunting. Not an early halloween but a Good Opportunity to learn from the past and look ahead to the future. Thank you for being here and joy and honor to be part of this event and impressive set of talent and deep knowledge of our Health Care System and Affordable Care act. And thanks to the panelists. I should say it is an honor that John Mcdonough is here and i have been reading about him for years and the project and rely extensively on his work. Last count, 40 times. I am not mischaracterizing anything too much. And grateful to tom and jack for organizing this event. I have to say i was initially a little surprised when tom emailed me to suggest holding an event my forth coming article on the Affordable Care act, although i like to think that people will read my work. It hadnt escaped my attention at the time. You know the total number of downloads for my article on the research [indiscernible. Those downloads were me. You beat me on my paper. And obscure policy internet. Let me provide a little bit of background where this project came from and outline my argument. This project has been the back of my mind for a few years now. University of miami and i spend a class or two doing an overview of the a. C. A. And how it changed the american Health Care System and each time i have done this imstruck by how many pieces of the law have been repealed by congress, invalidated by courts or undermined in other ways. In the paper, i call these the ghosts of the Affordable Care act. And these ghosts include the Supreme Courts decision in nfib versus sebelius. And affected arins that fall into the federal aid coverage gap and include legislation passed in 2017 zeroing out the tax penalty for the individual mandate and repealing it and the mandate was considered essential to the a. C. A. And believed that the law couldnt survive without it. The Available Evidence suggests that zeroing out the penalty has led to higher premiums on the exchanges and there was legislation passed in 2018 and 2019 repealing two comp. Control, the cadillac tax and the independent advisory board. And jonathan grubber, the cadillac tax is one of the most significant provisions in the law and peter orszag called ipab one of the most important institutional exchange. The class act which was to establish a Longterm Care Program and those were repealed by congress. As a result of that repeal, millions of americans lack access to any longterm Care Insurance or forced to spend down their savings in order to qualify for medicaid and include the Supreme Courts decision in hobby lobby and sisters of the poor which wideend the exception of the coverage contraception coverage. It is important to emphasize a. C. A. Was ambitious packed with broitions most of which still remain. The a. C. A. Has proven to be resilient according to work by abby, mark, it is the most challenged in American History during the first decade of existence alone, it withstood 2,000 legal challenges and over 70 congressional attempts at repeal and congress has subsequently strengthened some of the laws provisions in important ways, most notably by bolstering albeit temporarily, a. C. A. Exchanges. The law has reshaped the Health Care System in important ways. While im not going to go into the impact, there are hundreds of studies on the effect of the Medicaid Expansion alone. But i think what has received far less fangs was that the a. C. A. That exists today is not the same as the law that was enacted in 2010 and after taking these goaforts into account at least in several respects the law that exists today is more modest in its scope in effect than the version originally signed into law. It is not common common uncommon for laws to be enacted. Provisions in the social act have been challenged many times. By contrast the extent to which the ghosts of the a. C. A. Have undermined the central goals of the law namely to provide Financial Security in the face of medical costs and access to health care and reform the Health Care Delivery system so it delivers less costly Higher Quality of care. These are major changes and at odds with the central goal of the law. These ghosts are surprising since their intention with the conventional wisdom saying that social programs are nearly impossible to get rid of. And this is supported by body of work in Political Science which offers a series of why it is difficult. And social programs tend to be popular and democraticically who elected representatives dont take unpopular actions. Once they are established and implemented, they develop strong convincies as well as mobile groups. Is conventional wisdom is iron clad when it comes to Health Insurance programs. In a recent survey of 11 different countries, except for a brief two year moment in australia there is no case which universal Health Care Coverage once achieved has been undone. I think it makes it all the more surprising not only have several important pieces of the a. C. A. Fallen by the wayside but the law came close to being invalidated or repealed on multiple occasions. If chief Justice John Roberts had report he hadly not changed his mind during debate of nfib versus sebelius, the a. C. A. As a whole might not have survived. My goal was to investigate why it happened, why in this conventional wisdom have so many pieces of the a. C. A. Disappear and why did it come close to falling by the wayside . To get my answer down into a single sentence i make the case that these ghosts and vulnerability stem in large part in tradeoffs that they were forced to make between enacting the law and entrenching it, ensuring that the law would survive over time. My argument is that some of the legislative strategies that we necessary to enact the law had a Ripple Effect that made the law politically vulnerable did you know the road and this argument draws on the Political Science literature that are called policy feedback effects how lace and institutions change their political environment. I tried to summarize the a. C. A. Enactment with this table. Just bear with pee for a moment. The a. C. A. Architects faced three articles which are listed on the lefthand side. Fiscal constraints, threat of opposition from key Interest Groups and Health Care Policy trap that by incrementally expanding coverage over time through jobbested coverage and medicare and medicaid the United States has undermined support for universal coverage since so Many Americans have coverage one form or another and wary of further Reform Efforts that would jeopardize the coverage they did have. And polarized political environment they relied on other democrats to pass the legislation. In response, reformers developed legislative strategies in overcoming these obstacles. Fiscal concerns, president obama pledged that the law wouldnt exceed 900 billion in costs and pay for itself, avoid opposition groups and strategy referred to at the table or on the menu effectively of negotiating with key Interest Groups or trying to push through reforms over their objection and then the Health Care Policy trap they settled on an incremental approach to patch the holes in the system than just completely overhauling it. It may have been necessary to enact the a. C. A. , they had what political scientists term self feedback effects, meaning they changed the political environment in a way that undermines the law postenactment and contributed to the a. C. A. These effects are listed in the righthand column. In the interest of time, i will go through the first set listed in the second row from the top. But in my paper, i am happy to talk about the other others in the discussion. Take president obamas pledge that the law would pay for itself and expenditures wouldnt exceed 900 billion over a 10year threshold. They may have been necessary to win the support of physicianically conservative democrats but had other effects that made it vulnerable. They led congress to slash subsidies for private insurance policies on the a. C. A. Changes and congress can only partially Fund Medicaid so states could challenge that and reduce the c. Immplet o. Score Congress Delayed the implementation of the main coverage provisions until nearly four years after the law was enacted. Reducing the generosity and delaying the implementation of the most popular parts of the law, they had effects of limiting support for the a. C. A. When opposition to the law was most intense. Some have speculated if the Medicaid Expansion had been implemented and the courts been forced to confront the real consequences of arresting away Health Care Coverage, it would have been difficult for the court to rerpd the medicaid provision optional, which it did. And for one thing the enactment strategies in the table a were geared to addressing more than one legislative obstacle. And its rather to illustrate how the legislative and to make it more volable post enactment. In the last part of my paper, i argue that these tradeoffs are not unique to the a. C. A. And reasons to think they have become more important over time. For one thing, the growing constraints of budgetary and fiscal concerns over designing Health Policy. Interest groups have grown more powerful over time and have a strong interest in preserving the status quo. Congress has implemented government benefits what political scientists call the submerged state which channels benefits through the tax code in ways that make those benefits less salient to the public or otherwise undermine Political Support and at the same time, the rise of polar risessation and life to legal challenges. Zill, one might push back at this point saying some important parts of the a. C. A. Are gone, it did survive or at least much of it did. But other recent and important social programs have not been as fortunate. For instance, during the covid19 pandemic, the federal government enacted a sweeping expansion to social programs which initially drew comparisons to the Great Society or to the new deal, but these expansions have for the most part proven short lived. The one prominent example is the expanded Child Tax Credit. In march of 2021 congress temporarily expanded the Child Tax Credit as part of the American Rescue plan and it was groundbreaking in having support to nonworking families and was credited with lifting 3. 7 million children out of poverty and to limit parts of the law, congress funded it for that tax year and supporters gambled that it was so politically popular that congress would be forced to extend the law but this proved incorrect and congress let it expire at the end of the year. They did recently pass a law that would reextend but i dont know if if it will pass the senate and only last through 2025 and substantially scaled back from its pandemicyear level. In light of the a. C. A. Ghosts and near death experiences, the experience of these pandemicera changes to the safety net and entrenchment tradeoffs, i suggest to you that conventional wisdom surrounding social legislation needs to be revised. In light of the weight of this evidence i suggest social legislation like the a. C. A. , the expanded tax credit is more vulnerable than the conventional wisdom would suggest at least during its early years. Now while my project is descriptive, trying to understand why the a. C. A. Turned out to be so vulnerable and documenting the effects of all these changes im p putting it out from the perspective that someone supports a more rebus safety net and using this legislation as a problem. I conclude my paper by trying to explore some ways that lawmakers might address this in the future and make legislation more durable. The one option is to do playing the game better. Mainly the political scientists working in this area have tended to argue that lawmakers should look at the feedback effect the way laws shape their political environment. Their argument is that lawmakers should be prioritizing not just enacting their bill into law but designing it so it will be politically popular and it will become entrenched and phasing in benefits as quickly as possible so it will be salient and traceable to government. This isnt revolutionary advice. Savvy politicians like f. D. R. Have been aware that the design of programs can affect and with some exceptions have not been followed in the case of the a. C. A. However i am deeply skeptical of this approach since my project suggests that the strategies to enact the a. C. A. Or other social legislation are dectly at odds with those that are geared towards entrenching these laws. To overcome budgetary constraints legislators can reduce the generosity of the laws benefits or implementation of those benefits further out to the future but that diminishes the effect of the law. Alternatively lawmakers can fund the benefits. And the benefits wont be extended. Instead of trying to play the game better, lawmakers need to change the rules of the game by targeting the laws and institutions that give rise. So i think two very preliminary pee prescriptive suggestions for how lawmakers might do this. My first suggestion is to target the specific obstacles that cause legislators that undermine entrenchment. They could ease the budgetary like the paygo process for lawmakers to prioritize their budgetary effects. Mill second suggestion is counterintuitive, limiting the number of veto gates and eliminating the senate filibuster. I said it is counterintuitive and scholars have suggested that although the filibuster makes it harder, it makes them harder to be repealed. But i suggest that because veto gate gives disproportionate power to a few members of congress they render more potent and make it more necessary to resort to legislative strategies that have selfundermining effects. If you think about a world where where president obama and the democrats needed 50 votes in the senate to enact the a. C. A. In 2010, if that had been the case, is that the version of the a. C. A. Tay would have been enacted would have been more generous and would have been implemented more quickly and more politically popular earlier on than the version we ended up with. I have no formal proof of this, the pro entrenchment effect would outweigh the antientrenchment effects of needing 50 votes to repeal the legislation and make social legislation more durable. These recommendations getting rid of the filibuster have been extensively dated elsewhere and have pros and cons that i dont go into but entrenching social legislation should be part of that conversation. Ill stop there. Thanks again. And i look forward to everyone elses remarks. Thank you, gabe. Chip. I feel forest gumplike. I have been around for a long time and not try to match toms witt. Gabe gave us a great overview, although in terms of his last remark and getting to 51 votes, i think he should think what obama if he had to deal with senator manchin and senator sinema. Whether 50 or 60, ill get to that in a moment. But the process is the process. Im going to talk about three things that reflect from some of the comments gabe made. First, i am going to go back into history and i have my own quote which is from shakespeare, what is past is pro logue. In terms of obama success and the republican opposition, they were two historical events that set the precedent for both, which are important to keep in mind. That is the first area im going to cover. Second, from my standpoint, congressional process is everything but at the end of the day, it doesnt matter, only one thing matters, two things, one is the will to pass legislation and the other is the votes. If you have the will and the votes you can figure your way through any process and we see that every day, if you dont have the will, you are not going to get the legislation passed. And i got an example that i want to talk about there which is a. C. A. And why it came out the way it did. And then finally describing the ghosts, i think in terms of the best laid plans that you were quoting robert burns, of what myself and men often go awry. And despite the expertise, knowledge and experience that goes into the legislative process and i will take issue with gabe a bit, the issue of laughability is important for those designing legislation. At the end of the day. There are things that you couldnt predict and just because you think you do it right, like building a house, you dont find out until you start living there some of the things that happened you never would have expected. First, in terms of past is pro log it is clear to me the success of a. C. A. Really was made by the obama administrations strategy, which was built on the failure in 1993 and 1994 of clintoncare and one of the four themes that comes through that guided that white house. One and this one i think is surprising in washington, the white house basically took no pride of authorship. They set out premises and the president wanted to get universal coverage, but he left the details to the hill and he negotiated and he played in the game but in the end of the day it was the hills product. Second he sought partners, not adversaries. Having been an adversary not wanting to be in 1993 and 1994, i can say thats no fun but it can upend the legislation and whether there are interests or stakeholders or whatever, they count, they represent the public in many ways and the idea of making them partners and bringing them on board made a. C. A. Possible. Third. And this fits with the model that gabe described, there was the notion that the framework for a. C. A. Had to be built on the Current System. Whether it was built on how the Current System operates or not may or may not be a reality and brian will point out a lot of problems with the exchanges that reflect that construct that was different than the previous individual market, but on the other hand, at least they gave the illusion in the design that they were building on what works in the Current System. We can debate it worked then or worked over time, but that was the notion. And then finally there was a lot of kabookie theater in the senate during the early consideration of the a. C. A. But in the end, the administration knew it was going to be partisan and only pass their model if it was a democratic bill. They would have loved to have bipartisanship. But i think the crashing of clintoncare in the senate at the end of the day showed that that wasnt the way this was going to happen. I dont think they had a choice. Thats the obama model and why i think they were successful. Why do republicans think that a major piece of social legislation could be repealed . We could be we peel in place, but repealed. I have a lot of experience with that because back in 1988 i was one of the people that developed the catastrophic law since its enactment. And then i had the experience im not going to call it the pleasure on working the repeal bus i worked for members of congress that both framed the legislation and then repealed it. And ironically [indiscernible] the first day the repeal was being considered on the floor i was instructed by the Ranking Member on ways and means give him a draft. And bill archer, the full Committee Ranking who at that point was the author of repeal with congressman done ellie asked me to write him a draft. I wrote one draft one day and the other next. But the bill was repealed and its noteworthy and i would argue there were three key members of the congress who made the repeal happen, congressman archer and congressman done ellie and senator mccain because senator mccain was the lead on repeal in the senate. It was this and then repeal was considered in the senate, he voted against repeal in place. A notion that a may scrr piece of legislation that had an important effect on major population could be repealed was already set in precedent. Now, we can argue about whether or not medicare catastrophic would have been phased and gabe set out some guidelines because implementation of it was problematic in terms of gaining public support for it, but putting that aside that set a precedent that ultimately to what was surprising to me in terms of its lasting power of the g. O. P. Repeal and replace that actually to this day set up former President Trump said he wanted to get back to repealing a. C. A. And second point that on the one hand processes everything, but its the wheel and the boats make the difference regardless of the process which is most interesting to me that a. C. A. Is unfortunate the unfortunate death of senator kennedy was the key matter that allowed the bill to pass. And why do i say that . Because at that point in time and whether its senator manchin or senator sinema in the Previous Congress that stood at that Pivotal Point back in the day it was senator ben nelson. And i can see no way that a conference report that would have satisfied the bulk of the Democratic Caucus in the house and the senate could have done in nelsons vote. When the senator unfortunately died, there were only 59 democrats and the senate looked at the house and said to the speaker of the house, if you want this bill to pass you have to pass the senate bill. There was a reconciliation later but at the end of the day i dont want to say that was covered but not much you can do in reconciliation to actually authorize all of the law that is a. C. A. , it had to be in regular order and thus it passed because the house was forced to pass the senate bill i should say the senate bill with all its flaws. And so we had a. C. A. So finally, let me look at some of the things that went awry. There was some discussion about the Medicaid Expansion and in a sense the fall of the Medicaid Expansion is to me full of so much irony. The irony is that everyone thought that the individual mandate was the ultimate pivotal and the Supreme Court stood by it and at the end of the day it was the mandate on medicaid on states that fell by the way side. I dont think the individual mandate arguably was that much of a material loss because if you remember krrmt b. O. Predicted 92 to 94 insured rate and we are at 92. 3 . So we are not too far from that. The 92. 3 is a little disappointing because we made a deal based on 94 assuming that hospitals would give up some of our payments if we could get that 94 . Who could have thought that the Supreme Court would have come become. Going back to the design issues, was it faulty design . You could say that on the one hand, but i think those people who are very expert in medicaid thought they were doing the right thing when they wrote the law. One of the most interesting things and ill conclude on this to me about a. C. A. Is not about coverage for the new programs, its actually about coverage for the old program, which is medicare. And a. C. A. Took cuts from hospitals and cuts from health plans. They were supposed to take 136 billion in cuts through 2019 from health plans. And c. B. O. , Congressional Budget Office estimated that there be reduction of 4. 8 Million People in 2019 from a total of 9. 1 million that enrolled because of the cuts. And what happened . And this goes back to plans awry. Because i think that those who framed the bill on the democratic side were not that enthusiastic about managed care and not enthusiastic about Medicare Advantage. Thats why we got Accountable Care organizations and other sorts of visions of how we would control costs and deliver organized care over time. But what happened . What happened was in 2019 and im not even going to talk about 2024, we had 22. 2 million enrolled in Medicare Advantage. And instead of a projected 6 67 member in rebates in 2019 it was 107. What happened . The bill had a nice Quality Program in there so if you got more stars, you could get more money. It was around 15 billion and the Insurance Companies figured gee, if i can consolidate with a 10,000 member plan that has all those stars and i might have 300,000 members then i can capatalize on all those stars and thats before we get to risk adjustment. Smart insurance guys created a situation where they could get a lot more revenue and actually provide a lot more upfront benefits to beneficiaries im not going to argue or value judgment it and then hired joe namath to sell it and more people in medicare and Medicare Advantage and with respect to the cmmi and the discussion about valuebased purchasing and a. C. O. s, at the end of the day if most Medicare Beneficiaries are going to be in some kind of valuebased coverage, its not going to on be c for service that is narrowing as a portion of medicare. With that, i hope i offered some pearls that will be worth of discussion later and i appreciate the outline that gabe gave us to this discussion. Thank you, chip. Brian has spent a good deal of his career sometimes to draws. Go ahead, brian. Thanks for allowing me to participate. Gabe, thanks for the painful and thoughtful trip down memory lane. The a. C. A. In 2024 is largely the law that the Health Care Industry would have written. The main components, the large new subsidies through the exchanges through Medicaid Expansion, through 340b are all growing. Health insurers reaped windfalls and enjoying their position. The main component that the industry disliked, cadillac tax, gone. Health insurance tax a, gone. Medical device tax, gone. The independent payment advisory board, gone. All in big partisan votes. The conversations in the board rooms of the Health Industry were to support enactment to get all the stuff they wanted and worked to eliminate what they didnt like and thats how it played out in a way that substantially increased federal deficits. In retrospect president obama guarantee that it wouldnt increase deficits had been made to get the law passed. As gabe discussed this, the Class Program significantly contributed to the laws purported deficit reduction. Thats because collections needed to come in for five years before any payments were made. One year after the enactment, secretary sebelius said the program had serious underlying programs and the administration would not implement. One year later, it was repealed. I dont think the student loan redesign which was used as an a. C. A. Payfor is working out in favor of the government. The core Central Planning aspect of the a. C. A. Has failed. I dont believe gabes paper, the centers for medicare and medicaid is increasing deficits that failed to develop models that improve health care and lower costs. And harming policy policy coverage. The first seven years of implementation of the a. C. A. Occurred with acome did iting administration and took many legal actions to ease political opposition to the law. Most famously, president obama admitted in the fall of 2013 that his promise that people could like they could keep plans if they liked them was in the true and they created a new set of grandmother plans tay could avoid increasing costs. If the Trump Administration done this, it would have been called sabotage. It provides significant relief from the employer mandate penalties and took action to offset the Medicare Advantage payment rediscs prior to the 2012 through an effective legal demonstration program. Let me move to the efforts to repeal and replace. It restricted plans and compelled people to buy coverage and new taxes from spending and enormous of washington Central Planning and it was unpopular. Intense opposition to the law should have been expected. That negative public reaction contributed to landslide election and ended any hope of acome did iting legislative policy for the a. C. A. Four republicans, the best chance to change policy direction would have been to capture the white house in 2012 since its core i provisions had not taken hold. One of the ironies in recent political history, they nominated the man least able to make the case against the a. C. A. Massachusetts governor romney embraced the elements of the a. C. A. President obama was reelected and the implementation of the a. C. A. Continued. But it went poorly from 2013 to 2017, planned deductibles soared and vast majority of coops failed. In 2016 repealing and replacing oaker obamacare was part of the platform and republicans gt the car. In 2017 we had the most significant effort to modify the a. C. A. Notice i did not use the phrase repeal and replace. It became clear in early 2017 that the leadership of the party was not supportive of significantly repealing the a. C. A. I think gabes paper makes a typical fault to say the a. C. A. Might not have survived for john mccains thumbs down. Most of the a. C. A. Insurance rules kept the subsidy in design form and permitted states to maintain their expansion just as traditional rate for medicaid not the enhanced rate and that legislation went too far for the senate. The socalled skinny bill only had three elements, elimination of the individual mandate penalty, the delay of the employer mandate penalty and what states could do using a 1332 waiver. If that bill passed the senate, the product would likely have been closer to what the Skinny Senate bill was and policy would be similar to what we currently have. The legislative effort failed for a lot of reasons. The one reason in particularly important, the Congressional Budget Office. C. B. O. Applied a mythical power to the individual mandate. If you remember, president obama had campaigned against the individual mandate, but his position changed because of c. B. O. According to c. B. O. The individual mandate would compel people to purchase coverage thus it made the coverage and cost numbers look better. These assumptions continued through 2017. Republicans reviled the individual mandate. Every proposal they would introduce would seek to eliminate it. Dough spite republican bills maintaining most of the Health Insurance, the individual mandates led c. B. O. To project 20 Million People would lose coverage. And although this number was bogus, as became clear once congress eliminated the penalty, the number was the top data point cited by democrats and media for have the republicans bills were harmful and it was devastating for the efforts. With respect to the argument in this paper, one of the main a. C. A. Designs that led to its entrenchment was the makeup of the Medicaid Expansion. With almost all expansion spending financed by washington, states had significant incentives to expand medicaid. By 2017, Many Republican governors expanded the program, and those that did did not want to roll back the federal money. It created a significant divide within the party. In my view dividing republicans in states on the Medicaid Expansion was has probably contributed to the a. C. A. s entrenchment more than any other element. There have been some conservative wins outside of the ones favored by industry. The tax cuts and jobs act eliminated the individual mandate penalty, the outsized and unrealistic effect of the mandate meant repealing it, led to outsized and unrealistic budget savings from fewer people getting subsidies, making it a useful pay for. Second, the refusal of some states to implement Medicaid Expansion. I dont have time to get into the numerous problems with expansion, but i encourage you to read a new report from paragon on the subject if you are interested. Third, the regulatory efforts of the Trump Administration to expand options for employers and families such as through shortterm limited Duration Insurance and individual Coverage Health reimbursement arrangements. Finally, chip mentioned this, Medicare Advantage has emerged in a much stronger position than experts expected. C. B. O. Thought m. A. Growth would flatline. The office of the actuary at c. M. S. Thought the a. C. A. Would lead enrollment in m. A. To shrink by half. Yet m. A. Has continued to exhibit strong growth. I think there are a few other assertions in the paper that are incorrect. Im going to mention two. First, there was not Trump Administration sabotage. The main administrative action taken by the Trump Administration was to comply with the federal tkort ruling court ruling that the government couldnt make caution kwrar reduction payments to Insurance Companies absent a congressional appropriation. This resulted in regulators allowing the practice of silver loading. Which vastly increased a. C. A. Subsidies to insurers. The Biden Administration could have asked congress to fund the c. S. R. Program. Its chosen not to. One other trump major a. C. A. Supporting policy, those individual coverage h. R. A. s, they are increasing enrollment in the individual market. Using employer dollars. Second, there is mixed evidence of the a. C. A. He effect on health outcomes. Life expectancy in the u. S. Decreased from 2014 to 2017. The first three years that the a. C. A. s provisions took effect with greater declines in states that expanded medicaid. In closing, let me offer perspective on policy moving forward. First, policymakers should rationalize federal medicaid subsidies. It makes zero sense for the federal government to pay a much higher percentage of state expenses for the nondisabled workingage population than for traditional medicaid populations. There is no sensible policy that would have resulted in that outcome, and federal discrimination against lower income children and people with disabilities through this disparate disparity should end. Second, as a recent paeuper from paragon discuss, the a. C. A. Exchanges was not an efficient coverage expansion. Its cost a lot more to decrease the number of uninsured than expected. Much of the subsidies have gone to people who would have already had coverage and people who pay nothing for their coverage. The subsidy structure gives insurers enormous Pricing Power to increase prices with the full increase borne by the taxpayer. Policymakers should not just continue to enhance subsidies and rather focus on a better targeted and more efficient structure. Thanks again, tom, for asking me to participate. I look forward to the discussion. Thank you, brian. Well squeeze our discussion because im contractually obligated to go to the audience. John, you have enough time. I wanted to ensure that. Last but not least, because he was flying in from boston this morning. Thank you, tom, for pulling this together. Thanks for gabe for incisive and really interesting look back. I think as tom says its always valuable to get some perspective and look back at things we forgot about and overlooked. I have some comments, differences in interpretation, probably with everybody. I do have a few slides. Im going to see if i can pull it up. Here we go. Heres my first one. Like chip, when i read the paper i thought back to 1988. Have we ever, in fact, repealed a major social welfare benefit lawn u. S. History . Yes, we have. 1989, 17 months after the law was signed by prede ronald reagan. I ow you cant take your eyes off that picture, and neither could i. Thats from left to gh thats johningell, henry waxman, otis bowen, standing near the front, dave durenberger, lloyd benson, max baus, pete stark surrounding ronald reagan. Forgive me the Power Pointer cutoff, john chafee and bill were in the picture as well. Look at x by the way. Does he look like a Young John Kennedy or what . Whs interesting to me, what stands out for me most aut the 19881989 passagend repeal is that it was a law that was the biggest expansion of medicare in history, and it was done by republican white house, republican senate, democratic house. It was fully paid for. It was fully selffinanced. No addition to the deficit or anything like that. And the Financing Mechanism put what was either a tax increase or a supplemental premium or whatever label you want to put on it on mostly the upper income seniors. That was the problem, wasnt it . Who already felt that they had good supplemental coverage on their own dime or through their employer. And they revolted. In many ways, particularly in chicago, against dan rostenkowski. A lesson there. A lesson to be learned of what happens when you have to pay for stuff and how difficult it can get. Ditto in 1997 the balanced budget act, democratic president , Republican House and Senate Passed a major bill to balance the federal deficit. Mostly by cuts to medicare on hospitals, on physicians creating the low Sustainable Growth rate. There is a lesson in this it seems to me that republicans incorporated from this which is that its tough to pay for this stuff. Maybe if we need to do stuff, we need to think more carefully about that. Its a lesson i think that carries into then the 21st century and what we can see. I took gabes provisions, the 10 provisions and i just tried to look at them in different ways. This was the way that i found most interesting. I put them in order of the date of repeal, number one through 10. Bottom two, Workforce Commission has never beerepealed. It was never funded. The coop proam ran out of money tt congress pulled back. But the othe ones you can see, you can look at the states. U can see how it was repealed. Two of the major ones by the preme court. And then the rest through statutes, most during the trump era, as well. If you look at the. A few details about it. And then my last column, we can probably disagree about, were these central in some way, fundamental to the a. C. A. . And except for the state medicaid mandate and the individual mandate, i woulday the rest of them, they are all important, they are all substantive, they all matter. And absolutely none of them were really central to the success or failure of the a. C. A. It turns out the individual mandate that we thought it was very central, and i did, too, turned out to be far less essential than we thought. Interesting, you look at the details and numbers five, six, seven, eight, they were all pay fors. They were put in there. They are substantive policy, but they were not put in because, geez, we have to do this. But because we had to do things to, a, finance the law so it did not add to the deficit. Democrats made a commitment right at the start, this is going to be scored by c. B. O. As deficit neutral, and that was a Mission Accomplished. However they got there. Whatever concerns you want to put. They did it. They met that requirement. Or it had some other significant impact. Interesting dynamic. Most of the changes happened, of course, during the Trump Administration. But there is one point that i really have to take issue with. Gabe suggested in his paper that, so a lot of these changes ended up undermining support for the law. I look at the dates of when things happened, and then look at this, this is the keyser Family Foundation kaiser Family Foundation monthly tracking poll of favorability, unfavorability for the a. V. A. There is a clear trend thats not hard to saoefplt i dont know what happened in january, 2017, but it was a turning point for popularity of the a. C. A. Of course it was donald trump coming in. Making his clarion call for repeal and replace. And since donald trump became president , a. C. A. Flipped to be consistently and growing more favorable than unfavorable. If the big change, of all the changes that happened, undermined support for the law, this chart doesnt make sense. And in fact, the law has become significantly more favorable. Over the past seven years, six to seven years now. Because its a core 101 principle of behavioral economics. People fear hypothetical losses. More than they aproerbite hypothetical gains. So when donald trump came in and said we are going to take all this away from you and just wait two weeks and well tell you whats coming and its going to be beautiful and youll love it, then no one ever sees it, people say go take a hike. It was a massive unprecedented resistance from the American Public that really defeated it and led to john mccains thumb down. I agree with brian, the skinny bill that came before the senate was nothing. It was just something to keep the process going. It would have still ended up in a car crash im sure. Then you look into this decade and the Biden Administration where the a. C. A. Played a Critical Role for the first time in American History since we have been counting the number of uninsured, we went through a sharp economic down turn, and we saw no spike in the number of uninsured. The uninsured rate stayed the same. It marginally went down. Then the Biden Administration put in the extra subsidies for arpa and through the i. R. A. , can you see the popularity in the law. I think the notion that there was a decline in popularity became hard. I dont think that holds water. I did a piece a few years ago for the journal of Health Policy politics, and law on the 10th anniversary of the law, where i wanted to look at some of the provisions that people dont write about. I just this is the title i used at the top. I have the reference at the bottom. I picked success, failures, and mixed results. My count is there a 487 sections in the Affordable Care act as it was signed into law and amended by the followup law. In that, when you have 487 sections, you have winners, you have losers, and you have somewhere its a matter of disagreement or so worth so forth. I think the important thing to keep in mind is that whpb the a. Did within the a. C. A. Structure, there are the major league provisions and there are the minor league provisions. The major league provisions are title 1, we thought the individual mandate less so. But the advance payment tax credits, the subsidies, the insurance exchanges, the marketplaces, and most of all fundamentally guaranteed issue, all of those that came together, you go with those. Thats what people were going after in some of the Supreme Court cases. And you would have done fatal injury. The Medicaid Expansion in title 2, you get rid of that, you have blown a major hole in the a. C. A. And then title 3, the valuebased care revolution that was envisioned with reshaping American Health care. It has the the results have been far less to write home about than people thought in the first decade. But that was central. That has never really been challenged at all by either party. What i would note is just one thing to keep in mind, if i can go back here, the pay fors. Interesting. There have been by my mind there have been two major Republican Health laws in this century. The medicare modernization act in 2003. And the mack a, created the mips program in 2015. Both of them overwhelmingly defici financed. Not paid for. You look here in this, the pay fors, the four pay fors in a row, all done by republicancontrolled congresses. And they did which had significant revenue impacts for the federal government, because the benefits keep going and these were pay fors. Any attempt at any point to try and pay for any of these by the people pushing this repeal, answer, no. I cant tell you the number of articles i read since i got into this game in 1985 on how awful the tax exclusion for employer sponsored Health Insurance is. Bipartisan. Particularly, though, republicans hate it. When the cadillac tax was repealed but it was put in the law because max baucus was ordered by harry reid that he could not he could not mass width the employer sponsored Health Insurance tax exclusion. Couldnt do it. It would be a failure. We would lose so cut it out. Baucus had to go back in. It was john kerry who came up with and pushed the idea of the cadillac tax. Ok. Absolutely flawed. You look at it. And you look at the design and so forth. You can say thats just what made them think that that could do it . What were they smoking that day . The important piece is that when it came time to repeal it in 2019, which ever year, 2018 or 2019, was there any consideration or effort to say, ok, we cant keep the cadillac tax, but what an opportunity to go back and try to come up with Something Else to try to modify it . Never to my awareness a conversation about doing that. Lets just so i guess part of my consideration is that paying for Health Reforms in federal law in the United States, in this century, the 21st century, thats so 20th century. That just doesnt happen anymore. Im wondering what happened to the efforts on the part of republicans like durenberger, like khaeufrby khaeufrbee, when you chaffee, when you try to make changes, you have a deficit, it has to be paid for. I havent seen an initiative from republicans in this century now, 24th year, to pay for the changes they want to see. I put that out there as an observation. Ill close on this. People have been saying, oh, a. C. A. , it didnt meet its targets. No coverage. Waste of time. Big waste. You cant say that anymore looking at where we are on medicaid and on the exchange coverage. We have the rate of uninsurance in the United States to the lowest it has been since we started counting. Not Mission Accomplished at the level that chip thought we would get, but when we wrote the law we never thought we would have Medicaid Expansion be a state option among other things. But substantial historic progress. Then the other thing we get is people say, ok, yeah, you covered some more people. But you didnt save a dime. No changes at all in costs. Youll get the look at the date. Look at the date when it really starts to fall up there around 2010. When it levels off. That was the precise year that the big major cuts that chip had to pay in title 3 of the law took effect. And went on. And continued. Its not the only piece. Its not the only piece, but to say the a. C. A. Didnt save a dime, this is 4 trillion in medicare spending that people thought was going to happen that did not happen. Just to note that on both sides, on this 14th anniversary on both coverage and on costs, its definitely not a home run. We are definitely not done. We have major challenges ahead. As we look back i think that we also its hard to say that on both coverage and on saving money, that we didnt make significant serious Important National changes. And i think thats the piece to keep in mind. Im sorry, not the long laundry list of little provision that is got saved or didnt get saved. Thank you. Thank you, john. I was about to have to file for cloture. We appreciate it. It would have been a lot of rebuttal on the panel, we need to go to our audience with the time remaining. Lets wait for microphone to come to you. Introduce yourself. Short of the oped. Just the question. Start in the back. Go ahead. Thank you. This is this was really informative. Paul with nefron research. Id like the panels opinion on what the prospects are for the enhanced a. C. A. Tax credits depending on the outcome of the election . Especially if we have a republican washington next year. Quickly. One minute apiece at most. Go ahead. I think it does depend on the election and what happens. If you have a democratic trifecta, the likelihood is it will get extended. Probably not for 10 years because it costs so much. If you have a republican trifecta, it will probably disappear. And if you have a divided government, it will be a jump ball depending on the configuration and the stage is set for a deal between, on the one hand, continuing the subsidies, and continuing the tax cuts from the 17 tax cut law. If there is a deal, i think this is possible candidate as a major component of the deal. Brian. I think the last part that have is a good point. There is a lot thats expiring at the end of 2025. The trump tax cuts on the individual side are expiring. They have set up other cliffs that are expiring. My hope is that the subdy, which i think subsidies, which were inefficient, if republicans are in power, they would not extend, and if they do they would just do it for enrollees who already have them and not allow new people into the enhanced subsidy structure. Move along. Carl. Carl, worked on Health Policy for a long time. Im with both john and brian. I think they both made really good points. Brian, the fact that the Health Industry basically wrote the bill, made a lot of money off of it, and we have too High Health Care costs. John, i think youre right. Most of what the a. C. A. Promised, it did. It covered about as many of the uninsured. We still have 10 we need to cover. We need to cut costs. We need money for social security. We need money to reduce the deficit. We need money to help people raise kids. Stuff like that. The question being what would you guys do with this Health Care Industry out there thats so powerful, either to enhance government bargaining or private sector bargaining to get our costs down more in line with other countries . On the supply side of the market we should look at undoing Government Policies that increase prices. Medicare pays more for services delivered in hospitals that could be provided in physician offices. We should pursue cite neutral payments in medicare site neutral payments in medicare. On the subsidy side, paragon has a proposal that would direct more of the subsidies away from the industry and away from direct payments from the treasury to Health Insurance companies to the individuals. And let the individuals have greater control over the subsidies and over the spending so that they are making decision that is are maximizing their value and they have incentives to be cost conscious consumers. I think its important to point out that the same number that john shows us in terms of where medicare spending is is reflected in overall spending. Im not arguing we dont spend a lot on health care. But the amount thats being spent has plateaued and the key thing here is getting all those people covered. The a. C. A. Was with respect to brian and what you said, was not about the providers. It was about assuring that we had a framework that covered all americans in this country. Because job one was making sure they had Health Insurance coverage. It was not completely successful, but tpraeubgly frankly, considering what else could have happened, it was extremely successful. And most americans have coverage today. If you go to california or go to new york or some other states where they have completely implemented a. C. A. , except for the undocumented and a few others, everybody has Health Care Coverage. Wendall. Your mic is behind you. Thanks for this discussion. I enjoyed it very much. Ill make a couple comments. The folks at home love to know who you are. Wendall, now at brookings, i was a long time staffer to speaker pelosi. The issue of medicare catastrophic, i point out at this point i get the blame for the credit for that because i convinced rostenkowski that the elderly should pay for this expansion of the medicare program. But now we do have an income related premium in medicare. 9 of the elderly pay for t. They got the tax anyway. And they didnt get the catastrophic coverage. And i do think we have some big discrepancies discrepancies between the a. C. A. And medicare that arent going to stand both on the premium side and catastrophic. The only thing i would say is i think a lot of the implementation dates in the a. C. A. Were not politically determined. They were just determined on how fast we thought the provision could be enacted. Administratively implemented. I make those comments. Thank you very much. One other thing, brian, i do nos still paid for, even though we got rid of some of the pay fors. Its all on the credit card. Its paid for. One more in back. Well have to jump. We are about to hit a hard cap. Hi. I have a very about the perceived value of a. C. A. Plans. When you look at the introduction of the expanded a. C. A. S usdys, we saw the majority of those in lowincome were paying about 25 for the plan before increasing subsidies came. Now we are seeing the largest growth in a. C. A. Enrollment is among those seeing zero dollar subsidy for this. How do you explain that before, when the plans were 25 we had no enrollment. Now that they are zero dollars, there is a lot of enrollment. We are clearly there is an issue here with the perceived value of a. C. A. Plans. Moving forward how do you reconcile the true consumers of the a. C. A. Not thinking their plans are worth spending money on. But the federal government continuing to fund it. There is a difference if you at a low income. 150 of the poverty line. There is a difference between 25 a month and zero a month. If you are living at that close to the poverty level. So it does make a big difference in terms of encouraging people to get in. Frankly, the purpose of it is much more to get people covered rather than to squeeze 25 out of them for a month. I think you see the results in that in terms of the enrollment. I think its got a good societal benefit. And we also in this process went through covid. When people were quite scared about their health and wellbeing and felt a real need to have Health Insurance. That is one of the reasons why we also had this bump as well. Now that people have it, if they can hold on to it, they will, unless they are caught in a state using a. I. To do their redetermination process. Remember, part of this is coming from those who were disenrolled from medicaid, who were on medicaid during the covid period and then the states have kicked them off medicaid. We are talking about really lowincome people. We are going to have to even go ahead. You started this. Go ahead. Wendall, thank you for your point. In response to the question about whether it delays in implementation were due to needing time to implement the thing or whether they were trying to change the c. B. O. Score. Dont think those two things are necessarily exclusive. I know a similar point was made a paper. From my reading from the legislative history, i would be curious if other people agree, the c. B. O. Score also played a big role in that decision to sort of shift back the implementation of the main coverage provisions to 2014. I would be curious to talk about it more with you. There are tons of other comments everybody on the panel would like to make and has made. And will make again regardless, even on the subject of time limits here. I want to thank you for being here. I get in the last word. I would point out a couple of quick things. Sales versus service. One thing to sell the legislation. Another thing to make it work. There are problems in assembling majorities. Real majorities and getting that is the first thing. The middle thing, and last thing. Everything else works around that. You cant assume a majority by saying this stuff will be great. You have to count the votes an keep them there. And people lose their jobs otherwise. The other thing about c. B. O. Scoring of the individual mandate and other a. C. A. Provisions its like love story, never having to say youre sorry. They do it at the front end and dont bother later on. Thats more than enough. I dont know if we were going on a snipe hunt or a ghost chase. This law has a ghost of a chance of continuing into the future. But in the apockry tpal quote which is not accurate, asked about the french revolution in the 1970s, said too soon to tell. He was talking about the student riots in 1968 in paris. Its a good story. With that we are going to end our story today. I thank you for coming. Thank our wonderful panel. Hope you come back again. [applause] [captions Copyright National cable satellite corp. 2024] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy visit ncicap. Org] coming up, First Lady Jill Biden speaking at a Campaign Event in atlanta ahead of georgias 2024 president ial primary. Watch live at 2 45 p. M. Eastern. Here on cspan. Today, watch cspans 2024 campaign trail. A weekly roundup of cspans campaign coverage. Providing a one stop shop to discover what the candidates across the country are saying to voters. Along with firsthand kpbts from political reporters, fundraising data, and campaign ads. Watch cspans 2024 campaign trail. Today at 7 00 eastern on cspan. Online at cspan. Org. Or download as a podcast on cspan now, our free mobile app, or wherever you get your podcast. Cspan, your unfiltered view of politics. Cspan is your unfiltered view of government. We are funded by these Television Companies and more. Including mid co midco. Midco supports csp as a public service. Along with these other television providers. Giving you a front row seat to democracy. 2024 republican president ial candate, and former president President Trump was joed by Texas Governor greg abbott for a visit to the u. S. Mexicoorder near eagle pass, texas. Ey discussedssues, Border Control agents confront dealing with illegal crossings. The formerresidents trip to the southern border came on the same die preside biden met with Border Patrol agents along the border. This is just under 30 minutes. This is just under 30 minutes