Good morning. I hope you enjoyed the dinner last night are bright eyed and bushy tailed this morning. I have a couple of panels in the wings by chance. Rumor had it that i did. I see them coming. There is a handwaving. Very good appeared its good to see you. I was going to have to do a monologue for an hour. That wouldve been something. How are you . Grab a chair. We are now going to have a debate. We are going to have a classical republican versus democrat debate. It seems to be the time to do such a thing. Weve got repeal and replace in the wind and a very polarized nation. This is impacting ocelot. We thought it would make sense to invite a couple of representatives from the left and right. In terms of format, let me provide introductions to these gentlemen. We will out each of you to make a statement, maybe three or four minutes to provide your perspective on where we are in health care and then we will talk. Been a guests has couple of times. Ways inade his mark in this city working for both the Obama Administration and the drafting of the apparent aca and before that with the clinton administration. Is wellknown and very much a democrat. Pollet to represent that in our polarized world. Lanhee chen is a fellow at the hoover foundation. He is one of the top three leading voices on the right in terms of health care reform. Rubio an advisor to the campaign. You see his writings everywhere. He is a superb speaker and a good gentleman. With that, why dont i join you. I will let you go first. Regalis with your thoughts. Regale us with your thoughts. Chris jennings i do feel i should go last since we are in the minority right now. We have a little bit of energy now thanks to the republicans, which we appreciate. It usually when they are divided among themselves, its not because we are good at all. A vision and dysfunction that only does one good things for republicans, it camouflages hours. Rs. Ou i think you see an extraordinary time in the health care debate. You can talk about the polls and asked, it is significant that there was no other issue that pulled as high among voters as did health care by twentysomething points in virginia. There are cross cuts on this that are probably necessary to look at like economic security. Care really health dominated the domestic policy discussion this year and the political one. That was done as a consequence and result of an almost yearlong debate in an attempt to repeal and replace, which from our perspective we are pleased failed. That, you have a big debate from repeal to replace all the way to single they are. The democratic race is moving in that direction. There is frustration on both sides about our Health Care Delivery system. There is discourse and attention focused on exchanges. That represents 8 of the marketplace. Most people get their health care through their employer and 92 of the Media Coverage is on the exchanges and the individual marketplace. That filters a misperception of what our Health Care System is and what the challenges are. I think the big issue among the public there is frustration with complexity and outofpocket costs and that is a huge driver of the debate today. I think canada to only focus on exchange on any level are probably missing the vote on having an engaged discussion with the public and how they are thinking about this. That, the debate around the Affordable Care act has anchored the discussion. Look at almost everything that has been focused on, i like the last discussion. It validated and affirmed what we know in this room, health care is as much local as it is national and it is affected by both. There are huge differences and dynamics at every level. That filters into the political discourse as well. I will stop with this in turn it over. Lonnie. Where we are today, i would say the marketplace is not as bad as some people think. The irony of the withdrawal of the costsharing reduction payments mean that more money is going into the system to subsidize at higher levels. People can buy gold and bronze plans for much less than they would have their subsidize. Those who are in poverty are being exposed to high premiums and low benefits. That needs to be addressed. I would predict the markets and insurers participating will have a good year in terms of revenue intake. It doesnt mean its perfect. Healthcare is here needs reformed and thats why we all have jobs. The title of this panel is the saga continues. Rather than a star wars movie seems likely been to groundhog day with a star wars. A few observations. The first is that we went through a tumultuous time when republicans were coming at the problem from Different Directions with the same outcome. That predicts that did the same thing again next year. Were likely to see a similar effort next year on repeal and replace of the ca empire because of the political and parroted. If you look at Public Opinion polling or with voters in particular youll find a majority of them, literally still believe the top agenda item for congress to deal with his repeal and replace of the aca. If you think about the echo chamber that members of congress are getting in their home district they hear the ac is a problem and something has to be done. That suggests that even though they went through a lot of difficulty in dealing with the aca, they still feel a strong motivation, desire, and need to do something. 2018 and the tax reform debate, that will wrap up in december or july, depending on who you ask. It wraps up before we get into 2018. But i think we come back to discussions on the future. There is a policy issue here there are concerns about where things are going in some of that is in the marketplace. Set a huge number of people were talking about. Some cases do make for good media. Using stories about rapidly increasing problems also the quality or nature of the plans are changing soon have higher deductibles and less access to physicians. Those are Problems Congress the to deal with. Ideally in a bipartisan matter. The Energy Reason for bipartisanship right now. The second observation is that were an interesting time with respect to the healthcare on the progressive left. In my view, its interesting how quickly we have gone to a discussion around government run single payers, and the reason people call it Different Things because things registered differently. Medicare for all does better than singlepayer. That seems to be the way to talk about say dont scare people into thinking were turning into a european country. Now its interesting how quickly the discussion has migrated. Because the next election is never far away, the reason people are migrating is because will get to 2020 ahead of the next president ial election, in order to be successful as a democratic candidate for president needs to have been there early than other people. Thats why youre seeing this dynamic. Its remarkable that we havent had more earnest of a about singlepayer systems in the united states. We will see that debate. We will see that discussion we will see a significantly as we move into 2019 and approach the 2020 election. Republicans, would they settle in terms of what they wanted for the aca . More and more republicans agreed the way forward is emphasizing themes of federalism. He saw this in the past proposal of grandma cassidy. That focused on giving stays greater freedom and flexibility in the form of a block grant. And also loosened a lot of regulatory structures. I think it was probably too far, too fast. But it signals where republicans will be comfortable. If theres anything it exposed is that republicans dont agree on a lot when it comes to healthcare policy. Its a healthy thing to have disagreement and think about the future of healthcare policy in a thoughtful way. If you are to pull 100 republicans in congress, one thing that we get the most support is federalism, greater responsibility. Whether the foundation is the Graham Cassidy legislation or loosening the requirements of section 3032 waivers that allow states flexibility to design their Healthcare System so long as it complies with syria and benchmarks the ac establishes. Whether it is broad or narrow, i think well see effort on the right to migrate the discussion to the value of federalism and healthcare policy. I think its an interesting time because healthcare is never that far away from the center of a discussion. Theres a discussion about where republicans put into their tax package repeal of the mandate. When he makes healthcare and tax debate, bad things tend to happen. Its an interesting time. We will see a lot of discussion around healthcare. The republicans made a promise to repeal and replace. Weve seen their efforts to uphold that. Skinny repeal, Graham Cassidy. I want to break it down. There is a lot to the Affordable Care act. And we need to look at a little bit. All of those republican attempts included provisions that wouldve had the effect of rolling back the expansion. Why . I think there are a couple of reasons why. The notion of putting medicaid on a fixed federal medication has been around for a long time. Thats probably motivated by two things. One is a sincere sense that the federal obligation for medicaid is growing. Relatedly, theres a sense the program has gotten to break and that has to do with the expansion of medicaid through the aca be abroad and its good. Whether its a fiscal issue, those are the people policy motivations. The other side is an argument that if republicans want to undermine the aca the core of what the aca did is the Medicaid Expansion. Whether you think its a good idea or not we can agree that Medicaid Expansion explains some of the coverage increases in the aca. The other part is the politics. If you want to strike about the aca, getting at the Medicaid Expansion would be a big part. You can make the argument that youve done something because you have the aca. But there are some who like it and are comfortable with rolling it back. I think people realize that. Theres a sense that republicans wanted to roll it back. The coalition is more limited than we thought. But all the attempts included that rollback. And possibly be increases slated because you get to the rollback that the future across all of the efforts. Im also hearing you say that it cannot be afforded. Is that true . Are those cost borne by somebody somewhere somehow, whether its clinics or Emergency Rooms across the country . Is fair to say nothing is free. So we need to look systemwide to figure out if theyre not absorbed by medicaid where they observed. Theres another issue just which is the most effective way to cover the population . In some states medicaid is very effective. In other states, less so. The variation across states something issued out and say i have an example. When youve seen one Medicaid Program, you seen one. Theres a lot of variation. Theres an argument to be made that medicaid is consuming a greater percentage of the federal budget. Is that a useful expansion of federal spending . Wes would argue it is and someone argue it is in because theres more effective ways to get there. Is that doubletalk . I feel sorry for lonnie. I mean if you like on double teaming. The medicaid debate exposes a couple of important points. There are republicans in the senate are liking it. But also the stakeholders in the providers. There thinking its not as bad as it thought it was going to be. Theres a funding stream now going to get payment for. Guess what, theres republican governors to expanded. So yes most people in washington who is the most effective opponent of the repeal and replace, its the republican governors. They had more of an impact than anybody else. The second issue medicaid when you look at the Media Coverage of legitimate policy problems raised its largely been focused on the exchanges. The Medicaid Program expansion, slashes that was expanded in a significant way with little negative reaction. Working quickly to repeal and replace that policy rather than focusing on the exchanges was a political mistake. Medicaid has become stronger than it has been other be no reference about this. Republicans needed offsets to reduce some policy they wanted. I would argue, im pleased they strategically made heirs but not to go just to repeal the expansion but to cap growth of the Medicaid Program. That brought in different people into the argument. For these reasons, i think it was a huge mistake. The last thing, you often hear medicaid costs and growth is outofcontrol. But on a per capita were growing at a very low level. Its probably the cheapest way. The reason my democrats expanded is the cbo score is less than the cost because he couldnt secure the coverage at less of a class because of lower rates. Its going to be hard and i would argue against it. One other thing i think they made a mistake about strategically what happened right after the election which didnt exactly turn up where hoped or expected it was expected that we would have a quick repeal vote. It was a certainty. But what happened was suddenly the media focused on this debate and the way they hadnt. I republicans who revealed this many times didnt feel that debate because they didnt feel it was going to happen. I dont think republicans were prepared for that and they were produced for that product that the media was hungry for. Trump said i would never repeal something without replacing it. In that moment republican said okay we have to repeal and replace at the same time. Expose those are ready to produce a product that could sustain a consensus. Going forward in the aftermath at least i hope so. Theres issues of affordability and so on but underneath the more fundamental question of right versus privilege. Then it becomes more graphic. Where is the country in 2017 . Where the two parties with answering that question, is that a right or privilege . I think what is happened, this is a change, and evolution. I may be a revolution. For the most part now republicans are saying we want to cover everyone but we want to do it our way. I went big criticism they have is it and cover everyone. Which is sweet, i like that. But the political notion that we should be covering everyone whether writer or privilege, and no one should be exposed to discrimination. I think it has been folded into the ethos of the debate. That makes the alternatives of the Affordable Care act not single pair that are difficult to achieve. I disagree with that lately. It is not the case still amongst all republicans that is it an agreedupon bully. Lets all just agree that the goal of any reform that needs to move us towards universal coverage. I cant tell you how much blowback i got from that. Not from your people, my people your people are very supportive. It was not surprising. You can come over to our si side. What was surprising is that there are disagreements within the conservative movement about whether coverage is an meaningful metric or not. Its still very much, so i republicans are having a difficult time. If all republicans agree that we had a be moving towards that it would be different. We dont even have that, theres more disagreements the fundamental terms of art. I think youre correct i think people in the Republican Party are saying coverage is not the best metric, sin honest way of addressing this issue. If you pretend otherwise, you can come up with the policy. What im suggesting is a political messaging is counter from the underlying opinion. That creates problems in terms of reconciling policy then rhetoric. I get confused hearing all of this. We had some of that here yesterday. What is wrong with the exchange . We heard congressman talking about the rising premiums in exchange. Members observed that there rising outside of the exchanges well. And whether or not they need to change the justification for opposing it. Whats your perspective . Why should it be curtailed or removed . I think there are some technical questions for example in some situations you have private marketplaces that are growing that have been stunted by some of the regular pieces put in by the aca. The problem the exchanges are experiencing are symptomatic of the Health Insurance system more broadly. I wouldnt say its in exchange specific problem. So theyre looking elsewhere. Regulatory uncertainty has been a problem on the exchanges, and if you look ahead to 2018, if you try to discern why premium are rising in 2018, i think most of observers would say that a good chunk of that has to do with uncertainty around the payment of the costsheriffing cost cost sharing. There will elements of the law when they were written that werent written in a way that were precise or werent written in a way that anticipated these problems. So the easy want would be, lets go back and fix those. Unfortunately that has gotten caught up in the larger political discussion around repeal and replace of the aca. I dont want do undersell but some states theres a significant problem with patient mix, insurer competition, rem proms premiums going up. Should this justify the repeal oall of exchanges . Issue i think. Answer that in light of the recent open enrollment where the numbers are higher than they have been in the past. I think that it ended up being a binary discussion. In an ideal world, yes, you would just go and fix create you would pull the levers you need to pull for insurers to participate. No quarrel with that but thats not the reality of where we are, the reality is, exchanges are a part of the aca. If you dont like the aca, you cant like the exchanges. Thats just the politics im just being honest. While i see a series of technical corrections could be made to improve this, you look at the proposal a bipartisan proposal on the table from senators alexander and murray, that would make some of these changes that both side would say those are reasonable things you need to do but it has go got close zero traction because of the environment were in. Chris. Just so many things in the exchange. First of all youre right to raise that premiums have gone up another context. Its not just the exchange. But also i think its appropriate to say that the nonindividual market is the hardest place to make the marketplaces work. You have a much more volatile population going in and us, people if youre an insurer pre aca and post aca always a problem and as a consequence always be some challenge that exist that dont exis