The 14th anniversary of the Affordable Care act is later this month. N Enterprise Institute hosted a discussion on how Health Care Law has survived and changed over time. And by republicans efforts to repeal and replace it have failed. This is about 90 minutes. [inaudibleversations] good morning, everyone, welcome to the american Enterprise Institute, and todays event, chasing the ghost of the Affordable Care■n act. Decided not to go with Abraham Lincoln vampire killer, but we work on that. First, i am tom miller, senior fellow at the american Enterprise Institute and periodically i always talke d you do with the Affordable Care act. I think the Obama Administration for necessary. I think the Trump Administration for making it more litigious and regulatory. And i think the biden tion for being more nostalgic and reflective. So thats where we are at the moment. But this is kind an annual newsy in terms of getting with the Affordable Care act. They comes up with the anniversary of the person you say is not another one of these anniversary events. I mean come on. We up to now . 14 or would ever since the ena in march 2010. Theres been a lot of changes since then and will talk about today but its not quite like another ghostbusters sequel. Are up to five of the net as a matter of fact. That one coming out later this year after life, after earlier i that one of ice. Now the son of the late original director is a one directing it. They had a female cast for number three. This one is perhaps going to be trying cryogenics. Not suspended animation. Thats just for the actors were appearing in it as opposed to the ghosts. We will try to do, bypass the pf the Affordable Care act and get into something i have to admit ive l a of false old slides have been used for while and am trying to reduce my Carbon Footprint so i tried recycle them. Whats attracted my attention to revising this topic is i need to ship it were quite a while. An excellent paper on the couple months ago by a younger professor there are you new communication can Gabe Scheffler and it was picking a fresher different look at the many iterations of the affordable ca what didnt. Thats reason for this title and forthcoming law review article, the ghost of the Affordable Care act. It also looking not only were we been so what am i say about what can happen in future. Theres a bit a force field around health care or policymang things that cant be done and get a nice job of explain■9 why we ght get in thew we can get Something Different if we change things around. Then we will have, gave his professor miami law school, of the background and at the white house, council of economic advisers, couplee and that cant so solicit from him as a first name speaker in the three different perspectives on that basic thesis. We will start with chip kahn whl get when anyone. Hes head o the federtems. We used to call them for profit but the work on the messaging of the call them taxpaying. We just do it for the folks out there really. Nothing else. Not only does chip at background in terms of the hostile sector and being a hospital of things in the witnesses past, in a previous lifetime he were a different hat for the health insurers, Health Insurance association of american have to havekx sliding reserve which is both harry and louise, i probably wouldnt use it. We can go back to 1980 when he was on capitol hill in one of his two tours of duty, also there for the nude revolution but this is one of working both sides of the catastrophic chapel talk about this site get someone experts about the legislative and the outside, their stakeholders duck, not special interest. But anyway to him or about how early goings and through time. Then our next speaker will beis. Brian is head of fairly new Health Policy think tank which has a lot of impact. Particularly among republicans and on the right butany ideas to offer. But again brian has wall street is before the Purchase Point person for Health Policy change is not reform, different opinions on that and in the trump white house. And prior history on capitol hill b side and on health side. Just a little bit after the enactment of the aca. Brian has been ae to use as a Supreme Court once being a Research Assistant at aei and the rest is history. In terms of what hes developed into since then. A bit of a content but hes been able to overcome it. Our final speaker, we have a range of perspectives can is John Mcdonough whos been on john was there in the sin which is important ingredient here, or get on senate health, education, and labor committeeith, under i. Inside national healt reform, about 12, 13 years ago. Good lessons of that. John also has other life. Hehe was once a practicing politicians we knew how to run for office and get elected and get those on occasion. None of us have to do wch i respect [inaudible] were all recovery in different ways but thats correct. So john will be our last speaker. I may have some additional thoughts i cant think of but i will come up with is affecting the public and will go to q a. That our basic format for or le. The speakers, and then the format. I have a lot of shot in time. I was either inchoate pandemics on the first rule of comedy, im asking a lot. Is you cant have a tight tent in order toet if youre going to Health Policy comedy, youve got to be able to have it organized lesson from there. Lets see what we got. Simple slide, et cetera but hopefully triggering some roundl ssanalysis. So first, why look backward to move[td ■u forward . Well, thats the best i can do. We got some things that this history that matters. Those who dont remember the past are condemned to repeat it. Okay we can start withne. Go to different direction. Try to karl marx. History repeats itself. Ve tragedy. And mark twain, differed little bit. He said history does not repeat itself butt final comment on ths probably donald trump that history does repeat, it just retweets. In any case welldo take a lookt what weve got to look at that. The fact is we dont know much about history in theu7■z same s, repeated and the witness movie, pl we dont know much of it history. We dont know much biology of whats in the science book but thats an education policy problem. A good bit of amnesia of happened or we remember it selectively come to have stories about what it is. There may be other lessons we didnt quite getnd and equipment and thus want to drive do looking back in this. Theres also some science and biology. In terms of National Health reform, wlicy reform reminds mes likely to be all while not until 2038, the cicadas come out, just kind of annoyed for a while and they go away. Sometimes our iteration of national Health Policy are more frequent the net, and sometimes they dont always get crushed underneath and Software Needs afterward. The supposed a convergence of twofe of cicadas, coming in of the parts, illinois and parts of the southeast but were going to miss that this time around. Coming to d. C. This time around. All these different breeds of Health Policy if you want to do this more as a promised you from the sides but would instead look at Health Policy and u. S. In terms of luck when he give you quantum physics. Ill just do newtoan laws of motion. The idea here is weve got centripetal fly apart and then centripetal motion in terms of it pulls it back in. Basic inherent stabilizing forces even things will be chaotic and then what really cements things together is what is a more powerful force in the universe than competent interest which isi inertia. Thats how we mostly hold things together. Periodically there may be somee looks like to be some wild swings but we never quite managed to completely go off the rail. Try a diffe image for the Affordable Care act. Might be a little extreme but ii can move in the direction. I decide not to use black night from the holy grail. Lets go back to the 1940s, the only dramatic movie Ronald Reagan is remembered for in kings row where he explained what happened was the local town physician cut off his legs to spite him because he was dating the wrong group of whatever. Theres this thing which i cant use with youtube rights when he wakes up in the bed home and he rest of the . Ok stucc hes missing both his legs. Some of the people who put out the aca might look around and say wheres the rest of the in terms of the provisions they thought were going to be in when they were fully of the middle le bit. I may be going a little strong on that part. I recom from 1942. The other thing i would have these, just remember what we hear a lot of lachaise. This is the lesson from bull durham, the interviews that you have to know your■d cliches eric weve got cliches of Health Reform and all the things it did. Did. There are nearly as many cliches in the acs acronyms and a lot of acronyms. Down to the stuff thats a little more lets see, running a little fast here. I probably have to have low bit of content in the midst of this. Thats wha i split second. The aca beyond age, at age 14. The reference to where is the cake . Those of you more inside sports fans, you might member in 2005 that having avi celebration, don at the capital city, they get two■]eady for the big celebration and he goes wheres of the cake . Kind of the same thing in terms of some of these aca anniversaries. Recent brief analytical overview before we move on to our speakers. Is a long time, memories are selective. We do then versus now. Not everything that was assumed those supposed to cee. But the magical thing is it doesnt matter if you damage or cut off a couple of those stools or legs on the three legged stool, as long as you have the magic of money and subsidies. When you have a rough crash landing on a few items and implementation, that money works as a wonderful flotation device. You just slip your seat cushion over and hold you up. There are a lot of tougher claims made about the aca in terms of everything it delivered. Certainly somed. We can its point amendment was but i believe that the audience here, o o discuss. But the main thing is keeping business in business and Internet Business did okay under the aca despite what were supposed to be. I make in some of the four seals the basic laws and motion but theres something when youre scoring this are urns out not to be the case. People were not predicting things like opioids, a covid pandemic, changes in eligibility rules for the various litigation and regulatory and his v changes whh ga a about. So what is the front instill into the same it all look like this in his what it will be. Turns out youre in a difficult because what you path isnt necessarily whated what stays around. Thats part of the larger message that theres the front in sale and that and afterwards okay what law article and have or as for scope would say, life is like af box of chocolates, yu never know what youre goingte o get into the open one up. In some cases the aca provisions work like that. In addition we have the fault of the war which made things donte was supposed to after the first shot about goes on. Ive gone long enough on this. Repeated at the end the lets go to opening speaker, gabe ghost hunting. That early hollowing but its a Good Opportunity to learn from the past and look ahead to the future. Gabe. , tom, thanks everyone for being here. Its really an honor for me to be part of this event, such an impressive set of panelists with such deep knowledge of the Health Care System and of the Affordable Care act pics am grateful for the paddles for agreeing tocipate and a burly looking forward to your remarks. I should see also its a particular honor to John Mcdonough here. Ive been reading his writing about the aca for many going to talk about today relies extensively on his wor my last count i cite your work around 40 times in my paper. Hopefully im not mischaracterizing anything too much. Im also grateful to tom miller and jack for organizing this■ event. I have to sayve though i was initially a . Little surpr me tot holding an event around my forthcoming article that goes to the Affordable Care act, myop w. It hadnt escaped my attention that at the time tom, the total number downloads from an article on on the social Science Research network was 13. I was an early adopter. Hly. I think six of those downloads were me. [laughing] you beat me onan papers. I have toms careful attention to even the most obscure corner of Health Policy internet, thanks for the invitation. This project camevidee from and then i will briefly outline so thiss project has been in the back of my mind for a few years now. I took a class of universe of miami and i typically spent a class or two doing an overview of the aca and how it changed the american Health Care System. And each time i have done this i have been struck by just how many important pieces of the law have been either repealed by congress, invalidate at leasterd in other ways since the law 14. So in the paper i call these the ghosts of the Affordable Care act. And s courts decision in medicn optional. As result of this decision around 2 million americans living across ten ten states includingre i live in florida still fall into the medicaid coverage gap and they also include legislation passed in 2017, zeroing out the tax penalty for the individual mandate effectively repealing it. As you may recall the mandate was once considered so central to the aca that it was believed the law couldnt survive without it. That hur wellfounded but Available Evidence still suggests that zeroing out the mandate penalty has resulted in a larger number of uninsured americans and hi there was also legislation passed in 2018 and 2019 repealing two important control provisions, the cadillac tax and independent payment advice report, or ipad come just to give you a sense of the kind of importance of these johnson gruber, the cadillac tax is one the most sfi provisions in the law, and peter or zag called ipab the most important institutional change in the aca. There■n was the cct which was supposed to establish a longterm Care Insurance program but deemed fiscally unsustainable in 2011 and was repealed by congress shortly thereafter. As result of that repeal, millions still lack access to any kind of longterm Care Insurance, or they are forced to spend down their savings in for medica. They also include the Supreme Courts decisions in hobby lobby and little assisters off the por which widen the exception to the acs contraceptive coverage mandate and undermined before the access to contraception. And i could go on. Now, its important having said all this to emphasize the ac was incredibly ambitious law packed with all kinds of different provisions, most of which still remain. Indeed, from one perspective the ac has proven to be remarkably resilient. So according to work by abby, mark, the ac is a most challenge statute in American History during its first decade of existe alone. The ac listed more than 2000 legal challenges and over 70 70 congressional attempts at repeal. And congress has subsequently strengthened some of the laws provisions in important ways, most notably by bolstering albeit temporally assumpsit on the aca exchanges. Has reshaped the Health Care System in important ways. While not critical into the acas and tax year, even the subject of extensive analysis and discussions in either literally hundreds of studies just on the effect of the Medicaid Expansion alone. But i think whats received far less attention and what i decide to write this article was that the acs that exist today is not the same as a law tha■l in 2010r taking these ghosts into account it becomes apparent that at least in several respects the law that exists today is more modest and its scope and the version that was origiy. Now of course its not uncommon for loss to be commended for change after their enacted. Longstanding laws like the solstice could act had been amended numerous times without seriously undermining the program. But by contrast its a the ghoss of the ac have an immense sum of central goals of the law, namely to provide Financial Security in the face of medical costs and kind of basic level of access to health care, and also to Reform Health the Health Care Delivery system soso it delivers less costly, Higher Quality care. In other words, is a major changes and they are at odds with another central goal of the law. These ghosts are somewhat surprising since they are in conventionalthe wisdom, social programs are nearly impossible to get rid of once they are inactive. And this conventional wisdom is supported by influential body of work in Political Science which offers a few reasons why and getting rid of social programs is so difficult. For one thing social programs tend to be popular and democratically elected representa