Medicare/Medicaid and Social Security Anniversary Event: a faculty roundtable

>> Good afternoon and welcome. I'm Susan Collins the Joan and Sanford Weill Dean of the Gerald R. Ford School of Public policy. And it's really wonderful to see so many of you around the table. To have so many distinguished friends with us today. As I welcome you to what is really an important conversation that is hosted jointly by the Ford School and the University of Michigan's Institute for Health Care Policy and Innovation. As you know that the topic is the 50th anniversary of Medicare and also the 80th anniversary of Social Security. We have a number of distinguished friends around the table and all of you have their bios. Those of you who are joining us through the webcast the bios are available online so we won't do lengthy introductions, but I do want to particularly welcome our two guests of honor. First, Congressman John Dingell served Southeast Michigan in the United States Congress for nearly 60 years. He is the longest tenured congressmen in US history and the lives of the people of the state of Michigan, and indeed the lives of all Americans are really better for his decades of principled service. He is the recipient of the nation's highest civilian honor the Presidential Medal of Freedom. Please join me in welcoming our good friend Mr. John Dingell, welcome. [ Applause ] And we're also extremely pleased to welcome our current Congresswoman Deborah Dingell. She was elected last fall to represent Michigan's 12th Congressional District. Debbie's work in DC builds on her own decades of service in Southeast Michigan and alongside a very highly successful career with General Motors. Debbie Dingell has served on the boards over a dozen extremely impactful nonprofits related in particular to women and to health policy and healthcare. And that includes the Karmanos Cancer Center and the Detroit area March of Dimes. Please also join me in a very special welcome for US representative Debbie Dingell. [ Applause ] So today we celebrate two major milestones anniversaries in US policy. July 30th marked the 50th anniversary of the creation of Medicare and August 14 represents the 80th anniversary of the creation of the US Social Security Administration. The past, present and future of Social Security could very easily be an entire symposium on its own and then some. There is much, much of importance there, but we have decided and planned to focus today's event primarily on Medicare. And so we have gathered some of the University's top experts in healthcare policy around the table. Our cohost for this event is the director of the University's Institute for Healthcare Policy and Innovation. Dr. John Ayanian. And he is certainly among those experts. And so to set the stage for the conversation that we will have today. It is my pleasure to turn things over to him, John. >> Thank you Dean Collins. I'd like to add my welcome to representative, Debbie Dingell and former Representative John Dingell on this special occasion, commemorating two the most important milestones in our nation's history. The signing of the law creating Medicare and Medicaid by President Lyndon Johnson 50 years ago on July 30, 1965. And the signing of the law creating Social Security Act by President Franklin Roosevelt 80 years ago on August 14, 1935. On behalf of the Institute for Healthcare Policy and Innovation at the University of Michigan we are very pleased to cosponsor this roundtable discussion with the Ford School of Public Policy. The mission of our Institute is to improve the quality, safety, equity, and affordability of healthcare with over 470 members from 17 schools and colleges at the University of Michigan, as well as 5 local partner organizations. A number of our leading experts on health policy and on Medicare in particular are participating in a roundtable discussion today. To set the context for today's discussion Medicare and Social Security have enormous consequences for the health and financial well-being of elderly and disabled Americans. Without Social Security one quarter of elderly Americans would fall below the poverty line but with Social Security this proportion has been reduced to 10%. Similarly, before Medicare was enacted about half of elderly Americans had no form of health insurance, but now coverage is nearly universal for senior citizens who often have significant health needs. In our population of 320 million Americans nearly 60 million receive Social Security benefits and 55 million are enrolled in Medicare. As the baby boom generation continues to turn 65 over the next decade, Medicare enrollment is expected to grow to 74 million Americans. These programs have major public budget implications for the federal government with 14% of federal spending on Medicare and 24% devoted to Social Security. Because Medicare represents 22% of all healthcare expenditures in the US it is also a major driver for how healthcare is delivered by hospitals, doctors, and other healthcare professionals. So let's move forward with today's discussion, we will hear first from representative Debbie Dingell, who will share her perspective on the important milestones that we are commemorating today. Next, we will hear from former Representative John Dingell, Jr., who was presiding over the US House of Representatives when it enacted Medicare in 1965 and whose father, John Dingell, Sr. cosponsored the Social Security act and was present when President Roosevelt signed this law, 80 years ago this week. After the Dingell's remarks we'll have an open discussion led by Dr. Matt Davis. Matt is the Deputy Director of the Institute for Healthcare Policy and Innovation, and a professor in the Medical School, School of Public Health, and Ford School of Public Policy. From March 2013 through April 2015 he served as our state's chief medical executive in Michigan Department of Community Health. Please join me in welcoming representative Debbie Dingell. >> Thank you [applause]. Thank you John for that kind introduction and for Susan for the two of you hosting this discussion, which I think is one of the most important discussions we're going to have for the next few years. John will give you more of the historical perspective surrounding the establishment of Social Security and Medicare. And I know we've got a great group of panelists that I'm very excited to hear from. I've been fortunate enough to know some of you, and even in the last week in spending time and finding more and more data out there that is reinforcing the need for updating policy that is, we will celebrate the 50th anniversary of Medicare at the end of July, and are celebrating the 80th anniversary of Social Security. And they're two very strong pillars, but they were written 80 years ago and 50 years ago. And it's time to talk about them, but I also think it's time to dispel some common myths about both Social Security and Medicare. We often hear that Social Security will soon go bankrupt. The fact of the matter is that if we make no changes to the program its solvent through 2033. And after that time, it will not run dry, it would still be able to fund 75% of current benefits. This gives us more than enough time to make tweaks to the program so current benefits can be preserved at the very least, if not expanded. We often hear that America can't afford Social Security given the national debt. Well, long-term debt is an issue, and I believe one that we have to deal with as a country. Social Security is not the main contributor to the problem. Cost for the program are expected to grow only slightly as a share of the overall US economy, and will remain quite manageable for the foreseeable future. The reality is America cannot afford not to have Social Security. Millions of seniors would be thrown into poverty. Millions already in poverty that have Social Security. And it would have a devastating impact on our economy as a whole. Social Security is the bedrock of our nation's safety net and the first step in secure retirement that our seniors have earned, and count on. Just as Social Security's become a part of our nation's fabric, Medicare is now woven into who we are as a country, and how we care for our citizens. We also hear that Medicare is going broke. But when you look at the facts that claim doesn't hold up to scrutiny either. The latest trustees report demonstrated that Medicare's hospital insurance trust fund will be able to pay 100% of all costs through 2030. Even in 2030, incoming payroll taxes and all other revenue will be sufficient to pay 86% of Medicare hospital insurance costs. Contrary to what opponents claim, Medicare will not cease to exist in 2030 as the term going broke suggests. I strongly believe that long-term care is the missing pillar of our social safety net. No program that exist today with design with long-term care in mind. Long-term care is unique and different from most health services. We're talking about helping seniors with activities of daily living. Like eating, bathing, getting dressed, or making sure that they're taking their medicine on time. Many seniors can do this in place. They can be contributing members of the community. They can keep their zest for life. And what we have now is designed for institutions. It's not dealing with, I've met the system, I've met it head-on, and it is broken, not navigable. I know that I'm luckier than 99.9% of the people in this country and it's broke. We all have loved ones who will face the possibility of needing long-term services and support. In fact, the demand for long-term care is expected to double in the next 40 years as our nation continues to age. And just in 2012, our nation spent $320 billion on long-term care. We spend a lot of time talking about Medicare and Medicaid but the reality is that neither one is designed to help seniors with those daily tasks. Medicaid's the largest payer of the long-term care costs covering about 42% of all long-term care expenditures, but it's got strict income eligibility limits. Medicare provide skilled nursing services and home health services only for a very limited period of time as part of a patient's recovery for an acute healthcare episode. And even then I tell you navigating the system, when you don't, even when you know what you're doing, has become almost impossible. Private long-term care is not always affordable or available and when people have it, the exhaust it way too soon. Family caregivers are often called on to support people during a time of me. However, the typical family caregivers spends about 20 hours per week providing unpaid care to family member for nearly 5 years, totally in a massive amount of time and energy. So it's clear that this problem needs to be addressed and not talking about it isn't going to make it go away. So we need listen to concerns today. Talk about these answers and talk about what some of these solutions are and try to change the conversation a bit. In Washington when you talk about this issue you often hear it referred to as a crisis, a catastrophe, a demographic ticking time bomb. And it's true that 10,000 people are turning 65 each day. But instead it instead of talking about it in the negative term. I think we need to refocus it on seniors' issues in craft a new paradigm. Let's rededicate ourselves to promoting the well-being and the independence of seniors. That's why one of the first bill, it's the first bill that I introduced in the Congress was a hearing aid bill. Most people don't realize that Medicare doesn't cover hearing aids. And we need to think about what that means for somebody that's cut off, the social isolation, what it does to a human life. And now, and this was one of the, I had a great meeting with some of the doctors around this table, who are beginning to do some of the real work that we need. Anecdotally speaking with people the first time I heard it, the doctor told me that 50% of the people that she saw who needed a hearing aid, couldn't afford it, and did get. We had a study done now, it came out in July that says 70% of the people who need a hearing aid between the ages of 65 and 84 don't have one. Now some of it we have men, one I was married to that were too proud to get it, but many of them is simply because they couldn't afford it. And that's, and things are, data is showing and it's more anecdotal than the actual measurement, which some of the very doctors at this table are working on that not being able to hear leads to early dementia, and to early Alzheimer's. This is an example to me of an ounce of prevention saves money in the end. So I want to thank everybody for being here. I look forward to this conversation and in talking about how both Social Security, Medicare, and talking long-term care are critical in this country. Thank you. Now do we turn it over to Mr. Dingell? You're on. >> Well first of all thank you for having me and the lovely Deborah here. I see a room full of dear friends and I thank you all for being here present. And I think you for your friendship and your kindness over the years, both to me and to the lovely Deborah. I am delighted to join with you and celebrate the 80th anniversary of Social Security, and the 50th anniversary of Medicare. Programs which have changed the quality of life for our people. Two percent of our people live decently when the reach maturity, and 65. The rest of them did the best they could living off of the charity of the public, or their kids, or the government, or something of that sort. It was not a happy life. My dad was one of those who was one of the authors of Social Security. And he was particularly delighted with that. And if you look, you'll see him right there behind President Roosevelt. A little skinny Pollock with a big broken nose and a mustache, and a smile on his face. That's an old picture it was taken at the White House, and those were the others who worked on Social Security with him. To the right is me with my dear friend Claude Pepper when we had finished the enactment of Medicare. Medicare and Medicaid are two of the then 22 titles of Social Security which came into law. Social Security is of course many titles. And it covers many, many, many things. The number has grown, I believe significantly since the time we did that. The most recent major addition to Social Security is of course the Affordable Care Act, or what is called Obamacare or whatever you wish. The simple fact of the matter is each of these programs has had savage, savage attacks upon them as they were going through. But the interesting thing is if you follow the savage, savage attacks you'll find [inaudible], they attack you, but they never had a cure. And if you'll listen to Gingrich, or anybody [inaudible] they say "We're going to get rid of it." And we say well fine, tell us what you're going to replace this with. The hard fact is, the medical profession, hospitals, doctors, nurses, everybody now supports Obamacare with the exception of one part of the medical profession. The harsh fact of the matter is that it has been proven that it works. And this system will collapse if we take this out from underneath it. I'm not going to go into the benefit of, or the faults of it, but the fact is it covers almost every American from the cradle to the grave now with some level of support. Those of you who have kids know that your kids are going to receive benefits. And know that they are going to be able to stay on your plan until such time as they reach 26. You also know that no longer are they going to be able to say that you can't have healthcare because you have a pre-existing condition, or other things of this sort. We had a youngster in the office who's paying about $330 for his healthcare and when we looked through and looked at all the subsidies everything else and he got what he got, what do you think? His total cost of his healthcare went down to about $30 a month, remarkable. And you're going to find that that's going to impact you. And there are other provisions in there, in which I will not go today, but understand that these are things which are important to all Americans. And are important in terms of seeing to it that the economy, the people, the kids, that we get the healthcare. One of the things that Truman found when he ran the investigation of World War II was Americans didn't have adequate healthcare, and he had a hell of a time getting them up to the level of standards where they could get proper placement in the military service. He did it. And then he found he had a hell of time educating them. And so we began passing legislation on schools. But in addition to that he also. But in addition to that he also found that he had problems with nutrition and healthcare. Those took rather longer. And the result was that ultimately, we have finally addressed those things. I'm not going to put you to sleep by giving you all of the benefits or the costs or anything, but this is one of the things that my dad was most singularly proud of. And that was that he had fought [inaudible] so that he could be in to move this forward. He was given 6 months to die, or to live in 1914. And he fooled them. The doc said, "John, you're going to die." And dad had a rather selfish remark about how he was going to be there. And he was. And it was one of his great prides that he was able to see to it that, he fixed it so that all of our people could have healthcare in both their young and their elderly years. And he introduced the Dingell, Murray, Wagner Bill as you will recall. It passed the house in bits and pieces, but never in sufficient form to do any appreciable long scale good. We finally got something close to it in Obamacare, and I'm pleased to say that it does do most of what we want done. And the interesting this is the medical profession, the health professionals, they all recognize what this is going to do for the country. They also recognize something else which is very important to all Americans. And that is the simple fact of the matter is that healthcare has become not just a commodity, but it's an absolute necessity for the country, for the people, and for the future. And if we don't see to it that they have what they have to have in terms of healthcare, we're going to find ourselves beginning to subside into a lower level of society throughout the world. I have found, as have we all, in the enactment of this legislation, that it's not easy. We've in each instance sought, to try to see to it that we have healthcare bills which meet the immediate needs. That has not been sufficient for our purposes, what we need to do is to have something which does sufficiency of it. This is going to take a long time to finally implement. You'll find that despite all of the threats and all of the stargazing and all of the nasty comments that the simple fact of the matter is that this bill is achieving success in terms of public support. It also is achieving success in terms of improving the healthcare of our people. And will continue to do so. Your job today, and that which I see being done around the country is to see to it that we have intelligent, honest criticism, which enables us to do the things which need doing. That make it in fact work. I always tell my friends in Washington when they start kicking up their heels about this legislation's not perfect, this legislation's not. I said well the last perfect legislation that was written in this world was the Ten Commandments and I've heard a lot of people complaining about them. So, your task now is to improve upon the Ten Commandments, to see to it that when the next opportunity comes, we're able to reform Medicare, Social Security, see to it that Obamacare does the things that we need. And that we are able to continue to see to it that our economy grows not held down by ethics, or by problems that we confront with regard to healthcare of our people. Thank you for having me. >> Well, Congresswoman Dingell and Congressman Dingell thank you so much for your insights you're your comments. I know I speak for everyone here when I say we're delighted to have you here this afternoon and have a chance to share with you some thoughts about, chiefly Medicare, and I'm sure we'll hear some thoughts about Social Security and Medicare together. You've both raised several questions that folks here around the table are addressing on a regular basis. So let me just say it's a privilege and a pleasure to serve as the moderator here. I'm not a timekeeper, I'm not a gatekeeper, but I'm sure everyone will appreciate that I'm going to try to make sure we hear from folks gathered here all around the table to hear about three particular aspects of Medicare. Number 1 is the people who are enrolled in the program. Number two are the healthcare providers who both of you have touched upon in your remarks. Who help deliver the services that the beneficiaries are looking for. And number 3 are the policies, because after all, Medicare started as a policy in and of itself, and has grown to become extremely influential and bid and subsequently been a hotbed for innovation in policy in the healthcare arena in the US. We're fortunate today to have many of our colleagues here around the table who have particular areas of focus and expertise in these three particular arenas. And I also want to say that it's very exciting to have this opportunity to have this conversation today and to work in a university where we do have this expertise. And where there's also a dedication to asking and try to answer pounds of relevant questions that are relevant at the local level, the state level, and the federal level. I know that we also appreciate honest criticism of the program. And we want to hear from both of you if you have questions or follow-up ideas about the sort of things that we discuss here today, because it's not anything, if it's not a dialogue about how we can try to improve the system. And how the work that we do here at university and in our communities and with our colleagues can help improve that system and how it functions. So we'll begin by reminding us all here that we are living the 22st century. And therefore what we say and the questions we're considering today are accessible through social media. And we have set up a Twitter account to receive questions from the outside world about this. Yes. So for those of you following us on Twitter right now the hashtag is hashtag Medicare 50 UM, Medicare 5-0 U-M. And as we have our conversation today, our support team here will be giving me the questions that we'll put forward to our experts around the table. All right, so dialogue aided by social media. This is really what it's all about in today's world. So let's begin with the people. We have some folks here around the table whose central work, whether they are clinician researchers or clinicians focusing on improving the care in the system itself, chiefly within the University Michigan health system are focused really on individuals who are today receiving those Medicare benefits. Trying to improve that system and how it functions for patients and those who love them and care for them. So I'd like a couple of my colleagues in particular, Ken Langa [assumed spelling] here and Brent Williams to get us started with a little bit about what their work focuses on regarding Medicare and the people it serves. Let's start with Ken. >> Okay thanks Matt, yeah and thank you for inviting me here, I'm really happy to be involved in this important conversation. I was actually planning to focus on what Congresswoman Dingell has already described probably better than I can, which is the key issue of long-term care and sort of the whole in Medicare if you will, in terms of funding long-term care services, or somehow increasing access to long-term care. Again, Congresswoman Dingell sort of highlighted these key issues. I'll just add a few numbers to maybe try to amplify the importance of this issue that Congresswoman Dingell brought up. So, and many of you have heard these numbers before I'm sure. About 46 million people now who are 65, or older. By 2050 that will be about 90 million people who are a 65 plus in the United States. A 65-year-old who was just entering the Medicare program in 1965 could expect to live about 14 more years to age 79, women a bit more than that, men a bit less obviously. Today, someone who's turning 65 and entering the Medicare program can expect to live 20 more years or so to age 85. So another 6 years of life expectancy for folks entering the program right now. There's also this key issue related to long-term care of who's going to provide that care at home. Again, the number of children per family has decreased significantly over the last 50 years since Medicare was enacted, and will continue to decrease because of the demographics going forward. So there's about 24 people 65 and older in the United States right now for every 100 people who are 20 to 64, the sort of classic working age population. That's going to increase to 37 older adults for every 100. So to add that up, again, so more older adults living much longer once they get on Medicare, likely with more chronic disease, which fewer kids to take care of people as they become disabled. So again to me that, long-term care issues around taking care of older disabled adults are important now, but will just, again, as Congresswoman Dingell mentioned, sort of explode in importance over the next 30 to 50 years. So I think we're going to have to deal with this somehow, trying to deal with it in a reasoned way that will hopefully use resources efficiently to address these key issues I think is, what I'd like to open up the conversation about. Should I stop there and then go on and? >> Well, I think you've actually created a great opening Ken, thank you, for Brent to talk about some innovations in care that can represent some opportunities to take care of the multiple needs of individuals receiving Medicare benefits in the healthcare setting. >> Great, I've been trying to follow this to know just what ball would be thrown to me at this point. It's a great pleasure to be here. Thank you for inviting me, great honor to be the presence of the Dingells and particularly enjoyable for me to kind of take a pause about Medicare. Because as I was thinking about this gather, my clinicians hat came on first. So I've been a practicing primary care physician and geriatrician for about 25 to 30 years depending on when you start clock. And through that time as I thought about the patients that I've seen, and their struggles through life, and their work in and out of the medical system and the healthcare system, the first analogy that came to my mind was the old song about the two fish swimming side by side and the one fish turns to the other and says, "How's the water" and the other fish says, "What's water?" There is much about Medicare that is underappreciated in the patients that I see and the students that I teach. And I think at this 50-year mark it's, if there's no other time to do this, now is the time to say the transparency of Medicare. Certainly around the acute medical issue. So I encounter, I work a lot in health disparities and I work a lot in teaching students about health disparities. And I'm struck by the fact that the every article, virtually every article, many articles start about health disparities saying among persons under 65 in the United States the following racial ethnic disparities. And that one sentence goes largely unheralded in the conversation with our learners and with our patients. I've seen bankruptcy after bankruptcy in people under 65 around acute care costs. But have never seen one, though they have done, it's happened I'm sure, but it's extraordinarily rare to have a medical bankruptcy for acute care in people above 65 who receive Medicare. And that is phenomenal. But patients rarely appreciate it, including my own parents. And worth a pause. It does take me though, to the issue around long-term care, which is see in my patients of course on a regular basis. I first came to the University of Michigan nearly 25 years ago with a mission to gather the database to create a home health long-term benefit. I thought we could do that because the money existed. And then a lot of things dried up, right back in the early '90s and I decided that I wasn't going to solve that problem. And it does persist, the cost of long-term care. Perhaps getting a little more to Matt's point. I have had the privilege recently the last 5 to 8 years of being a participant in some of the Medicare experiments. And here's another really key facet of what Medicare has evolved into. It has evolved into a self-examining experiment generating body, which is moving in many of the right directions fast as an organization like that probably can be expected to as political and costly as it is. So we hear, we're one of the first sites at the Physician Group Practice demonstration project, the PGP demonstration, or Medicare demo project back in 2006-ish. And that allowed us to recast the way Medicare dollars were flowing in, move away from the fee for service shackles and start to create care models that would benefit Medicare patients in ways that made most clinical sense, rather than generated the most visits and the most activity. And under that the shop that I serve as medical director for called the Complex Care Management Program was allowed to be born. We suddenly could afford to pay, as a cost center, a group of social workers and physician assistances to reach out to patients and without being able to generate a bill, nonetheless, find a business model that worked for us to provide them care. We've since gone on to new demonstrations here under Medicare, one of which is called Grace where we are putting, it was a model created by Steve Council [assumed spelling] and his colleagues at Indiana University, where we are able to put nurse practitioners and social workers into people's home, the frail elders who are discharged from the hospital, or not. And do an assessment in the home, because we can afford to do it now because of the way the payment is being reconstructed and reward and risk are being re-shifted under the Medical prospect of payment, or global payment options, which are continuing to grow. It's been a great privilege to be a part of those. I think I'll stop. >> Thank you Brent. One of the things you mentioned was disparities. And I'll turn now to John to say a few words about what we know through research and what we know about how policies in Medicare may have shaped the picture of racial ethnic disparities and other disparities in the medical population group. >> Thanks Matt, and thanks Brent and Ken for your comments. You know I think one of the least appreciated facts of what Medicare accomplished was within 5 years after the Medicare program being signed into law in 1965, hospitals that had been segregated for decades in large parts of the country, particularly in the south, that were not accessible to African-Americans, they were desegregated within just a few years. And we saw evidence almost immediately of better health outcomes for conditions where hospital care matters for African-Americans in this country such as pneumonia. And I think that's you know from a civil rights perspective, Medicare was enacted one year after the Civil Rights Act of 1964. And it really changed the face of healthcare in large parts of the country and started us on the path towards greater quality which as you know, after 50 years we're still striving for. But we certainly have evidence that for certain chronic conditions like diabetes and hypertension, compared to folks under age 65, those with Medicare coverage, if they're African-American or Latino, they're much less likely to experience disparities in how well their conditions are controlled. The quality improves for everyone with Medicare coverage and the disparities that we see before age 65 are significantly narrowed. We certainly still have challenges though in that we also see in terms of the care of certain acute hospital conditions, like heart attacks or strokes that minority patients are often concentrated in communities that don't have as many healthcare resources as other parts of the country as more affluent communities. And so the health outcomes in hospitals with those fewer resources are worse for everyone, but those hospitals tend to disproportionately care for minority patients. So I think one of the challenges that we see the greater degree of experimentation and innovation in Medicare is sort of how do we use Medicare dollars to promote greater equity and to create incentives or reducing disparities for improving quality of care in hospitals that may be historically deprived of resources, but with more support can provide better care as well as raising the standard for everyone in the program. So that we see you know some of the benefits that Ken described in terms of improving life expectancy. And certainly in the last 40 years, we've seen the gap in life expectancy between African-Americans and whites narrow from about 8 years of shorter life expectancy for African-Americans to less than 4 years. That's still a big gap, but we're making progress and I think we really need to emphasize this issue going forward. >> Can I add a [inaudible] to that? >> Go ahead Peter. >> I worked in the office or civil rights, HEW and then HSS from '77 to '86. When I started in '77 we still dealt with [inaudible] race claims. We would get complaints about the vestiges of segregated waiting rooms and how hospital floor assignments. By the early '80s we had very few racial discrimination, racial disparity claims, and it shifted then to the Americans with Disability Act, actually the predecessor to the Americans with Disability Act. So we shifted from race to disabilities in a very short time period. >> Thank you Peter. So we've heard now as part of the start to our discussion about the people receiving benefits through Medicare. We're now going to return to some of the work we have done here at the table around providers. And I'm going to turn to Maryann Udell Phillips [assumed spelling] and to Eve Curr [assumed spelling], whose work has focused on the organization of care in primary care practices chiefly, and also efforts to measure and improve quality of care. Maryann? >> Yeah so I actually want to pick up on something that Brent said, which is you know the measures may have disparities in the shift in to the Americans With Disabilities Act that had print the process of to the Americans With Disabilities Act for the shipment from right to disabilities in a very short time. They are so we've heard now as part of the start where discussion about the people receiving benefits through Medicare were not returned to some of the work we have done here at the table around providers and a turn to Marianne Udell Phillips and Eve Kerr, whose work has focused on the organization of care in primary care practices chiefly and also efforts to measure and improve quality of care. Brent said which is you know the exciting part of Medicare, and you know I can say this from having spent so many years on the private payer side, is when Medicare decides to experiment, everybody else pays attention. And one of the great things about the Affordable Care Act is it built in experiments under of Medicare, under the Centers for Medicare and Medicaid Innovation and it's allowed many of us to do things that we've wanted to try, particularly on the all payer side of payment strategies to improve quality and outcomes for people. And you know so Brent's point about these experiments, and you'll probably talk about the demonstration project, which was one of the first that Michigan got involved in, allowed, laid the groundwork really for us to apply. With our partners at the state, when Jim was running the Department of community Health for the state and with the private payers in the state for the Medicare advance practice demonstration project. And we were one of eight states in Michigan chosen to run that demonstration. It was a 3-year demonstration, Michigan and five other states have just been extended for an additional two years because we showed enormous success in reducing cost for and improving quality for Medicare patients as a result of this demonstration that brings all payers, Medicaid, Medicare, and the private sector together to expand the way primary care is delivered and really focus on treatment of particularly individuals with chronic disease. So we are in many ways, here in Michigan, because of what the Affordable Care Act did in partnership under Medicare, are really demonstrating that we can make significant difference, significant improvements in the cost of care. So important for you to know. We've talk a lot about how we lead the way in so many ways in Michigan, but it's not always known in Washington, right. And so I think that the demonstration project here, called the Michigan Primary Care Transformation Project, MIPCT is a great example of that. Great example of how we can really change the practice of care in ways that improve qualities and outcomes, and cost in the system. >> Thanks Maryann. Eve if you can say a few words about the quality research you've been doing and its relationship to Medicare beneficiaries. >> Sure, thank you Matt and thank you also to the Dingell's and I you know John mentioned that one of the kind of unheralded part of Medicare is the differences it has made in disparities. I think the other part that is probably a little known in kind of general conversation is the difference it has made in the way we think about quality of care, and the way we assess quality of care. So you know it was really because of Medicare and Medicaid both that we got the peer review organizations, you know back in '60s and '70s that started to really look at quality of care, started to assess quality of care in what patients were receiving. And that started a movement in many ways that continues today as Maryann said, in many different ways, with some experimentation about the best way we can measure quality and the best way we can improve quality of care. It was under Medicare that we got the prospect payment system, where we started looking at the way we deliver care differently, and we pay for it differently, but also a lot of fundamental research that had been done then to see, well how does that affect quality of care. And that's always been kind of put together when we make the changes and when we want to evaluate them. So I really welcome your invitation to kind of think critically about those issues in ways we can continue to improve both Medicare and the Affordable Care Act. And I think one of the things that is happening now in Medicare is that kind of experimentation and the experimentation about the way that we pay for quality, as I'm sure that others will comment, but also about the ways we think about what quality is and what value is. And that has great potential to improve quality, but it also has some dangers. And I think we have to think carefully about what goes into that equation. What goes into that value equation as we try to improve outcomes and decrease costs for patients. And in the end it does come back to patients. So one of the things that we've been trying to look at here at Michigan is ways to make those quality measures better. Ways to put patients back into the equation of quality. Because I think in some ways we remove the patient and we focus maybe too much on the organization. So I think the kind of the future of Medicare and the future of the Affordable Care Act gives us an opportunity to think about ways to measure quality that takes into account patient's individual characteristics, patient's needs, patient's risks, and very importantly, patient's preferences. Preferences for the way they want to get care. And that goes directly not just into our acute care, [inaudible] but also in long-term care. So that's the opportunity and I think that is something that we need to continue to think about as we assess value. And I'm sure Mark will also comment on ways to think about value and putting that back into, or continuing that with the Medicare. >> Thanks Eve. >> Could I? >> Congressmen? >> I'd like to mention something. This has been I think an excellent discussion. Two things though have to be addressed. First of all we've got to get a change in the political climate and move out that, getting a change that's going to do us good in terms of making significant changes in the way that society functions or manages cost is going to be very difficult. That's the first thing. The second thing is money. You've got to figure out how the hell you're going to pay for it. Now there's always this wonderful crowd in Washington that says, Medicare is going broke. Social Security's going broke. Medicaid's going broke. All these things are going broke. The country's going broke. And yet they won't look at the necessary things that go with finances. We have to have a major change in administrations and this has got to be, if you'll observe, like Lyndon Johnson Medicare, or like Obama Medicaid. Clinton tried it and he stubbed his toe with Mrs. Clinton because he was going too far too fast. And so that is a component we are not discussing today. And I have no criticism for not having done so. But I observe that is an essential component of what it is we've got to deal with. >> Can I say a word on that? >> Go ahead Maryann. >> I really want to say a word particularly on your point about the money because you know there's this proposal in Congress to eliminate the Centers for Medicare and Medicaid Innovation, right to cut that funding. And we've all been talking about how great that part of the Affordable Care is. And we're demonstrating results from that. But we're also demonstrating, it saves money. And so that's the thing so I don't know. >> That's what I wanted to go back. And I want to hear from everybody else, but I want to go back to Brent, because I don't you to abandon the idea you had in the '90s. I think we have to take what, I mean I have gut feelings, you all have metrics. And we need to take the empirical evidence back to Washington to show them. >> We ought to curse those people in Washington who knew the cost of everything and the value of nothing. And the result is that we have these idiotic parts that we're always [inaudible]. >> We need to give you that data. We have great data for you. >> And we need to take the data and start to build a business case. But keep going Matt, we don't want to. >> Well, I think these are really. I could see these comments just about to emerge, so I'm glad you brought them up. And I actually think we have some expertise around the table that can speak exactly these issues, so I'm going to turn to Dave Spallinger [assumed spelling] and to Jim Haveman [assumed spelling] to speak a bit about from their leadership positions as part of major organizations that have to deal with some very clear financial constraints, how does Medicare fit into the challenge? Whether it's in innovation, or encouraging systems to evolve. >> First of all I want to follow-up a little bit with what Brent said, and not a criticism, but we actually didn't get a global payment. But I want to [laughter], but I want, but the important thing was because Medicare had a demonstration project, it was the feeling of the university that this is where the quote, you know the famous hockey play, "This is where the puck is going." And that we were willing to put our resources up to invest into the complex care management system and our resources into changing the way we deliver care to enter into the MIPIC project, to be the coordinating center for the MIPIC project, which is 600 practices across the state of Michigan and continue this experiment. I can say we've been in this experiment since 2006 and every year, even though we haven't always hit the 2% hurdle to get to shared savings, every year since 2006 there's been, we've had savings to Medicare. And for 9 straight years. And so I can't tell you about this last year, because it's embargoed but it will be positive [laughter]. But and so I think that we've shown that we can make investments and change, and provide improvements in the way care is delivered, and both in the cost and the quality outcomes for patients. And so I think the experiments are critical. I think the CMMI is a critical part of the Affordable Care Act. And I think the Affordable Care Act is a good, it has its issues, but it's a good platform for improvement. I mean I think the challenge that we have is that people think that you know it's sort of this HL Mencken quote, you know, "For every complex problem there's a simple solution that's usually wrong." And it seems like the mentality in Washington is we didn't get it right. So we should abandon the whole thing and try again over. I think it's a platform for which we can continue to improve. And I think the CMMI is actually one of the most important things. And I think then the projects in the CMMI then have to be used to inform policy going forward. So for example, you know do we need to move away from the 3-day rule? In you know that you have to be hospitalized 3 days in order to get into [multiple speakers]. >> Answer that. >> But we should we that's one, just one, should we have a different benefit related to you know sub-acute nursing facility you know and how that's handled going forward. Can we do more homecare and what, and should we talk about virtual care? Right now virtual care is not you know, not reimbursed. And we could provide much better care in the home with virtual care. We have a program where we send, we send health care assistance to homes and then we virtually connect with both a physician and a pharmacist to go through I mean the problem is we go into homes and we see the candy bowl effect right the candy bowl full of different colored pills and they have to figure out how they're going to take, they somehow supposedly take those in the right, it's not going to happen. So you know I think that the CMMI is a critical part of the Affordable Care Act. And it's also, and CMS needs to also exert its influence, which it has in January this year and now it's creating a network to try and influence other pairs to move in this same direction, so. >> Thanks Dave. Jim can you sort of [inaudible] your perspectives on this? >> Well first let me thank you for what you've done for the state of Michigan, there's 1.7 million people who are on Medicare in this state, 2.2 million on Medicaid in this state, 600,000 on the Healthy Michigan Plan. So a total of almost 4 million people in this state get some type of support for healthcare. And that's a great step forward for the health of the economy of this state. I agree with you Congresswoman Dingell that long-term care, if you can address that and focus in on that. I mean I'm really proud of the innovation that Michigan does, and we can't do it alone. I mean we've worked hard with the universities, and Michigan's been a great player. But it's very complex. And you know it and I know it. Because we've had friends who've gone through it. I mean you've got waiver programs over here, you've got area agency on agency. You've got the nursing home industry. You've got the home healthcare industry. None of it's coordinated. So, you've got the PACE programs for the frail and elderly. If we can start getting some coherent approach, we would make a great step forward, especially with the number of people who are entering the industry. Michigan is part of the innovation and the whole dual program where you go the 200,000 people in this state who get Medicare and they get Medicaid. Two different programs, each spend $4 billion each. And if you can just put under one case manager and you can do a more holistic approach to healthcare, what a simple thing to do. We're experimenting that in Michigan, and I think it's going to make a difference. The other important piece is that the 2.2 million people who get assistance through the Department of Health and Human Services now, about 1.2 million are children. Michigan, 94% of the kids either have private insurance or public insurance. That is huge if we want to make a difference. The last statistic I want to tell you under the Healthy Michigan plan, which you all were key in making happen, 2 million people, 2 million primary healthcare visits are ready. The number of preventative visits that people have gone through, we are changing the behaviors of people. And if that's what we can do, we can start moving from a curative model to a more preventative model. And that's our goal, but long-term care if you can focus in on that, I think you'd find a willing partners to help you with policy. >> Thank you Jim. For [cough] excuse me. For our remaining partners around the table, we're going to focus on Medicare policy and how innovations in Medicare policy, some of which have been alluded to here are helping shape the Medicare of the future if you will. Because we know that 50 is still young, right. Heck [laughter]. And so what I'm going to do now is turn to a few of our experts around the table who are taking particular looks at certain elements of Medicare and its innovations and look to see how those innovations are helping inform our system today. And how future innovations might help shape it into an even better program in the future, excuse me. So I'm going to ask Helen Leevy [assumed spelling], and Mark Fendrick [assumed spelling], and Annie Ryan, and Peter Jacobson to wrap up our comments here. And we'll ask Helen to start out with some comments, perhaps about Medicare Part D and what we've learned about that program and continuing tinkering with that under the Affordable care Act. >> Sure. I think this follows up nicely on Congresswoman Dingell's point about gaps in these programs. Because one of the biggest gaps in Medicare was the lack of a prescription drug benefit for most seniors. And Medicare Part D reduced the fraction of seniors who don't have drug coverage from about a quarter of them to about 7%. So it has been a tremendous success in giving people access to this coverage and protecting them from the potentially high cost of prescription drugs. It did come with its own gap, which was the doughnut hole, which is being closed by the Affordable Care Act. So I think that sort of continued incremental progress in closing these gaps that has been the name of the game and will continue to be as we think about other issues, like the coverage of hearing aids, coverage for dental services. The underinsured. People who have insurance, but maybe not enough financial protection. I think the lessons of a program like Part D are very encouraging. And build on this idea that Medicare is still you know 50 is young. >> So picking up on Helen's theme, Mark, of the importance of pharmacy coverage connects into the idea of value and what you've been working on around value based insurance design. >> Thank you. I should tell you it's great to be here and Congresswoman, Mr. Chairman, my 24-year-old daughter just sent me through Twitter, because I told them that you, her that you rolled your eyes when you said we're doing this through social media. She says she lovers your Tweets [laughter]. And I should also say for those of us around the room, the chairman's background for his Twitter account is the big house, just like my daughter's so I didn't know that you had the allegiance to our football stadium. So you've got to be careful with everything you s ay these days. So, one of the most notable statements of the press conference from President Johnson signing the Medicare statute was seniors no longer would be designed the miracle of modern medicine. And you see from this day one issue that the cost of insurance was $6 a month with the employee had to pay 3, and I think we know certainly that it's the cost of healthcare that's being discussed much more so than the quality. And I'm very happy to have travelled to 49 states telling people that I did not go to medical school to learn how to save people money, that I really do believe that whether it be in state capitals, or in boardrooms, or in the hallowed halls of the US Congress, I think there's way, way too much attention being spent to how much is being spent, as opposed to how well we're spending it. And that's been kind of our spiffy soundbite of what we've done in this center for balance based insurance design. And value based insurance design emerged from the idea that even though American are covered, have insurance cards, whether it be in commercial plans, or now in Medicare, with the cost of care and the issue of copayments, coinsurances, and deductibles, there has been a rapid and real increase of what we call cost related non-adherence. And as someone who is just a gigantic fan of all things Medicare including Part D, it's amazing in 2014 there were more beneficiaries who had to forego basic services to buy their medicines with Part D than they did before Part D. So just that cost of everything are rising and we do have to make some real issues about what we cover, when and why, and whether it's things that are not covered, like hearing aids, or is the money issue that you say. You know I think that if we really focused on this how much too how well issue, we may make some progress forward. The great health policy researcher, Woody Allen said the best way to reduce expenditures is death. And we are not in that business. And I think that as I have had the good fortune to visit Mr. Chairman in your office several times, and Debbie your. >> Actually [inaudible] Congress have made that suggestion to the Republicans and you can't imagine the outrage that they let loose by [inaudible]. >> Right so this idea that both of you raise that the attention about the budgets and how much, as opposed to the issues of what we're spending and what we heard, you know from Eve and others that maybe we may go about this idea of spending our money better. And spending our money better on the supply side has been discussed by Dave, and Jim, and other, but we have focused on how to get consumers to spend their money better. And this value based insurance design idea is one that actually strengthens Medicare by created a benefit design that makes it easy to get the services for which doctors like Brent Williams would say, I beg you to do. And you might remember that we actually incorporated value based insurance design in section 2713 of the Affordable Care Act with your help, Senator Stabenow actually sat in Senator Kennedy's office, one of my great moments of my professional life and I think typed myself, part of what became the Affordable Care Act, which I have signed copies, you know hangs, your signature hangs in my office. So the good news is for preventative care, 137 million Americans including everyone with Medicare now has assess to high-value primary preventative service at no cost to them. The issue of course being both of you focusing on the money is 98% of Medicare dollars are not on preventative services, they're on chronic disease. So I get sad emails from patients that say, "Thank you for the free mammogram, I now have to foreclose on my house to get my breast cancer surgery." "Thank you for the free access to colorectal cancer screening, I can't get the drug that my oncologist tells me will cure this cancer." And we work very hard with both of your office to try to convince either Congress or the Obama Administration to create a value-based insurance design demonstration of Medicare. You helped us introduce a bill prior to the ACA Mr. Chairman and we were very, very pleased to see this summer, I'm going to say this slowly with strong bipartisan support. Strong bipartisan support the strengthening Medicare Advantage Through Innovation and Transparency for Seniors Act 2015, HR 2570 was passed this June. Greg Sunderman, both of your offices was a great help to us moving forward. And I'll just close with you know I see patients a day a week. My mother thinks I work for the CIA because I travel around all the time and not a real doctor like many people around the room. But I've learned firsthand that we need this interaction between policy and practice and both of your offices have just been absolutely instrumental to see these ideas that we generate in the academic setting to move forward. You might have heard in our world we publish or parish. Well I publish and still parish. Until our government relations team brought me to Washington, the first time since my fifth grade field trip to introduce people like you to ideas like this. And understanding completely that the political realities of what we do are absolutely essential. And I understand the vitriol and rhetoric, but in some circumstances there might be that fine place to talk about ways to make our seniors healthier, particularly the most vulnerable ones. >> Thank you Mark. And we've heard from Mark and Helen in large part about the benefits within Medicare, now we're going to talk with Andy about how healthcare systems are being restructured with encouragement shall we say from the Affordable Care Act and from Medicare. >> Well, thanks so much Matt. So I was just wanting to comment about some of the reforms in the ACA that are designed to improve the quality and value in the system. And you know they have gotten, not quite as much attention as the insurance expansions, but I thin, they're really crucial to the future of Medicare and its long-term sustainability. And so I think the timing of these reforms in the ACA has coincided with you know reduction of bending of the cost curve, of reduction in the rate of Medicare spending, but it's really unclear how much of that is going to be attributable to what's in the ACA versus other factors in the environment. And as researchers we're trying to do this, provide this honest criticism to see what's actually working and to say this needs to be expanded, this is something that can actually improve quality, improve value, and you know this reform not so much. I think what's interesting about payment reform is there's no silver bullet. With insurance expansion we knew with the 3-legged stool that a combination of you know guarantee issue, mandates, and subsidies would less than solve the problem, that we could get people covered and it would stable insurance markets. But we don't have that same set of policies for payment that we know are going to work. So we're experimenting with all kinds of things, studying the effects, and trying to expand them gradually and I think that's just our task as researchers. If we think about the history of Medicare payment reform, I think you know perspective payment for hospitals in 1983 clearly worked to reduce cost bill spending, but so many other things that have happened in Medicare, you know it's kind of mixed bag worked in some ways, maybe not so much in others. And I think that just speaks to the prerogative of continuing our work to study these interventions and to see what works and how we can expand value in Medicare. >> Thank you Andy, and now I'll turn to Peter who has additional background besides public health in the world of law. Yes. And has offered to share his perspectives about how Medicare has shaped some of the world of judicial and regulatory doctrine. >> Can I make a comment here that I think is important? Medicare, Medicaid, and Social Security are like [inaudible]. They weren't born, they grew. And the hard fact of the matter is we're always trying to see if those do what is needed, but we're always approaching it from the rear, not from the front. Yeah there's very little foresight that goes into these things. This is all stuff that we should have done years ago. Europeans did it, England did it in 1870 with good King Edward. Bismarck did it in the 1880s in Germany and Prussia, so we are just trying to get caught up. We haven't got the vaguest idea quite frankly what the hell we're doing and very truthfully we need you and the other experts in gatherings like this and through your communications with us of what is going on to tell us, "Look Dingell, these are changes got to be made." Now Dingell, this Dingell is out but that Dingell is in. And the fact of the matter is that if you will do that and the rest of the profession will do this we will make some effort and some accomplishment in terms of catching up and doing the things that desperately have to be done so that when you talk to us you'll be able to look at me and say, well here's that damn fool Dingell here again, and he ain't going to do nothing but give us a lot of sympathy. Well, we're trying to find out what's going to happen and hope that something will fall from this, but you guys who have the knowhow and understand the science and the technology and all the other things, and the psychology, you got to tell us what's got to be done so that we can respond. >> Now, I don't think I'll answer that question, but. And of course Bismarck had the Kaiser, and I'm not sure we want the Kaiser back to solve our. >> No it was Bismarck, it wasn't the Kaiser. >> Yeah. And we can talk about that later. So I actually, your point is interesting in terms of how the law has developed. Because it does evolve and if we were to look at when you signed, or held your hand out with representative Pepper at that time, what would the law of Medicare look like 50 years later, I doubt that you would have predicted what we have now. What's interesting about that to me, and I teach health law to unsuspecting graduate students, so my appointment is in the School of Public Health, law is pervasive now, and Medicare is one big reason. What's interesting about that gets back I think Representative Dingell to your point about Medicare being woven into whom we are. If we look at the development of judicial doctrine in Medicare from '65 until now, it's very difficult to see any clear doctrinal development or role. But you can't understand health law, without understanding how Medicare helped shape the institutions, the providers, and patient response, and how we develop law and its role. Second point is that in the future, I suspect we will see much more doctrinal development related to Medicare particularly around governance, quality of care, and possibly liability and anti-trust as the institutions take more and more control, the liability will change and for a lot of reasons. Anti-trust also through the Medicare shared savings program. But when you really see the effect of law in this area is on the regulatory side. So, my, so you made earlier suggestions, we need regulatory reform desperately. It's out of control. You look at how we regulate and largely through Medicare and Medicaid, you see a couple things. First, some real positive as a result of Medicare, the expansion of coverage determinations, technology assessment as regulatory matters. Maryann's point earlier about the incubator of ideas to be seen as a regulatory development. Quality of care that Eve talked about. The professional standards review quality of care, conditions of participation, arguably positive, not necessarily definitive. But then you start to see the fraud and abuse regulations. Which are mammoth and I think crushing in the sense that they impede legitimate arrangements in the marketplace that are effective for physicians and patients. So this is on the small blur side of ideas, but I think what happened is we now try to micromanage healthcare delivery through the code of federal regulations. And it's not effective. In fact it raises costs. It potentially harms patients. So we need regulatory reform that let's, the absent the policy missing, one of the policies missing from you know the Affordable Care Act. That's all. >> Thank you. >> That's all. >> That's a lot of great points. >> Very good so that's all she's written for right now. We've had the pleasure of sharing with you form several different faculty members here. Some of our current working thoughts and also we appreciate the additional benefit of hearing from folks like Jim Haveman and Dave Spallinger who have kindly joined us today to share their perspectives as leaders in the world of healthcare. And we have a few minutes for any follow-up questions or suggestions you have for us. >> Well I have a ton of questions which won't get answered in this short period of time. And one of the things I want to spent more time with Brent is why have you abandoned trying to [laughter] because I think that's the answer down the road. I think we have to talk about that and how we make it affordable, and that longer term it really can reduce costs. I want to, I think that I'm going to make a very parochial comment in one way which is I think some of the top research in the country is being done at this institution on a subject that needs real dialogue that most people don't understand the subject until everybody finally finds themselves in it when they're taking care of somebody that they love, or that they care about. And you know some people are lucky enough to realize how broken the system is and other people never figure out how to make the system work. I think there's very real data and metrics be done here and we need to educate policymakers about what the different issues are and how we really begin to have this conversation. You know Mary Kay Henry was in my office and SEIU and AARP was in and everybody's talking about we have to do something and I say, okay when are we going to stop talking about it and when are we going to start, okay how do we find those solutions. Obviously the data, the metrics, the experimental programs that are being done here have some of the foundation work and I suspect you're aware of where other work is being done around the country. I hate to say this, but I think that most members of Congress have no idea what's really happening at CMS, understand it, understand the kind of research that's coming out of the Affordable Care Act. I look at Jim and it reminds me of a day I think one of the happiest days I've seen in the last decade was Rick Snyder and John Dingell standing together and they both had a sparkle in their eye, which you rarely see either of them ever get [laughter]. When they. >> Not much reason. >> But my point, when they announced the health legislation and it was signed, and they were both being roundly denounced by both side of the party before they ever walked out of that room. But I think there's so many questions and how do we take the findings here and really begin to translate it into policy. When he was moving out of his office, I found a bill that his, may have been one of the, I shared this with Maryann, maybe have been one of the first Medicare bills. It was handwritten in the 1940s. And as you all know, Medicare itself didn't pass until 1965. And I found a million things that he had tried to do in the '60s that I was unaware of, which are now part of the library here at the University of Michigan. So you know the question is how do you take this conversation, broaden it, include policymakers across the country and really start to talk about these ideas so we translate them into, not ideas but into reality for Americans that every single day are facing crises that they need help in. >> I heard a fellow one time say that it would be very nice if some people would get down off the wagon and would help to push. And the guy who said that was a fellow by the name of Phil Graham, I'm not going to cite him as a story for everything in this particular room, but the simple fact of the matter is he was saying that we all ought to get together and push, well the hard fact of the matter is if this thing is going to be successful in terms of saving money and doing the things that we want it to do in terms of the time that we have and in terms of all the other constraints and limitations that we confront, it means that leadership is going to have to come from here and other people who know and understand and care. That's why what you're doing today is so valuable. And so if you will do what you do so well, and that is get out of the wagon and push, and you got to understand that [inaudible] is going to be pushing the other direction. And there's a whole bunch of bastards like that that you're going to have to worry about. But the question here is how soon can we generate the political forces that are necessary to generate the kind of support that we've got to have to make this darn thing work in the time that is constrained upon us by events in history. >> True. >> So true. >> Well I just want to take this opportunity to thank you as the Director of the Institute for Health Care Policy and Innovation at the University of Michigan, we really appreciate the opportunity to celebrate and commemorate the anniversary of Social Security and Medicare, which I want to thank all of our colleagues here, including the Director Haveman who's joined us from Lansing, and really sort of taking the time to reflect on how our work and what we're learning can help you create a better Medicare program for the American people in Washington, and hopefully do that in a bipartisan way that you know improves value, that you know gets us the best health outcomes that are possible with the Medicare program. And I hope we can invite you back to celebrate the 60th and 75th and 100th anniversaries of the Medicare program here with us in Ann Harbor, it's just been a great occasion. >> My clock is running down, I don't think [laughter]. >> You're going to be there. >> Susan. >> And we actually have one very special thing that we wanted to do quickly, but I don't want to not take just a moment to thank everybody for their comments and their thoughts, very helpful conversation which clearly is ongoing. And so it has a pleasure to host this and to have our special guests. But as our kind of wrap-up perhaps I will turn things back over to my friend and colleague, Matt Davis. >> Thanks Susan and Mr. And Mrs. Dingell, we heard that you may not have this on your mantel. >> We don't. >> And we thought actually in following up on today's conversation, this photo, which is a small version of that one there, the two victorious gentlemen of the Congress celebrating Medicare's passage is a photo of action. And that sort of action is something that we can get behind and start pushing the wagon. And hopefully this will be just a sweet memory of this conversation that we've had today. I know speaking for everybody, we have greatly appreciated the chance to hear your ideas about the future of Medicare and contribute some of our own. And may the best team win. >> Absolutely, thank you. >> We're all on the same table. >> That's right. >> Absolutely. >> Exactly. [ Applause ]