The Affordable Care Act: Where do we go from here?

0:00:01: I'm Michael Barr. I'm the Dean of the Ford School of Public Policy. I wanna give special thanks to two people who couldn't make it today, but who are integral to this event, Gil Omenn and Martha Darling. They have provided generous support through a health policy fund for today's event and other events we've held on health policy. I'm deeply grateful to both of them for their work together.

0:00:26: Before we get started, let me say today commemorates the 50th anniversary of Martin Luther King's assassination, which is obviously a deeply troubling event in our nation's history. And before Dr. King was killed, he was organizing a march on Washington called the Poor People's Campaign. And we have an exhibit in our hallway on the second floor that I encourage you to go visit on the way out, highlighting some of his work on this area. The Poor People's Campaign was designed to draw attention to poverty in America as a global human rights issue. And the King campaign saw to demand better jobs, better homes, better education, and quite relevant for our discussion today, better healthcare, to improve people's lives.

0:01:18: With many at the Ford School are dedicating their work to address issues of poverty and inequality through policy. It is my deep pleasure to introduce you to today's moderator, Associate Dean for Academic Affairs and professor of Public Policy, Paula Lantz. Earlier this year, Dr. Lantz was one of 52 distinguished social insurance experts to be elected to the National Academy of Social Insurance. As a social demographer, Dr. Lantz studies the role of public health and healthcare reform, clinical preventive services and social inequality in health. Her current research explores the potential of social impact bonds to reduce Medicaid expenditures and improve health outcomes. And with that, let me leave you in her capable hands to tell you more about our esteemed panelists today. Please join me in welcoming Dr. Lantz.

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0:02:17: Good afternoon everyone. Thank you Dean Barr, for your warm welcome and kind words. And I also do want to honor Dr. Martin Luther King today, by reminding us of one his many moving and compelling quotes: Of all the forms of inequality, injustice in healthcare is of more shocking and inhumane. So we've gathered here today to talk about healthcare, and one really important aspect of healthcare, and that is financial access to healthcare through health insurance. The Patient Protection and Affordable Care Act, or the ACA, was implemented in 2010, and by no means was a perfect piece of legislation, with a thousand pages as a law, and many times that in rules and regs, the ACA implemented some sweeping reforms and health insurance and healthcare costs in quality. With a well worn motto in public policy, of don't let perfect be the enemy of the good, and a few quick trips to the supreme court. The Affordable Care Act [chuckle] was implemented by the Obama administration.

0:03:29: This included new regulations for the health insurance industry, including a ban on pre existing conditions, medical loss ratio limits, and coverage for adult children up to age 26 with many of the students at the University of Michigan really appreciating that provision. The ACA also brought us the individual mandate. With few exceptions, everyone was required to have health insurance coverage. To assist with these goals, states were required to operate marketplaces for people who needed to purchase insurance in the individual health insurance market, with significant technical support and subsidies from the federal government. In addition, the Affordable Care Act allowed states to expand their Medicaid programs to non disabled, low income individuals who traditionally would not qualify for Medicaid. And this again was with significant subsidies from the Federal government.

0:04:24: The rate of un-insurance among people under age 65 in the United States was 18.2% in 2010. By 2016 that had dropped to a historic low of 10.3%. Even so, the Affordable Care Act has always had a loud, dramatic, and primarily partisan chorus of critics. With a new Congress and new administration in 2017, the Affordable Care Act has been threatened with full repeal, with repeal and replace, repeal and reform, and administrative sabotage. While major repeal efforts thus far have failed, the Affordable Care Act has been dealt some significant blows. This includes that the new tax bill and the individual mandate.

0:05:10: In addition, the Trump administration has pulled a lot of resources away from supporting and promoting the exchanges, and has openly criticized the Affordable Care Act during the open enrollment period. Other administrative moves have included discontinuation of cost sharing reduction payments, and more recently guidance for states to use section 11-15 waivers to implement work requirements for Medicaid beneficiaries. It's complicated as they say. Very complicated and who better to help us sort through all of this, than our distinguished panel of guests today. So please come on up and I will introduce all of them. Thank you.

0:05:58: So we are lucky today to have with us Dr. Gail Wilensky. She's an internationally respected health economist and senior fellow at Project Hope, which is an international health foundation. Among her many impressive prior positions, she directed the Medicare and Medicaid programs from 1990 to 1992. And served in the White House as a Senior Health and Welfare advisor to President G. H. W. Bush. Dr. Wilensky testifies frequently before Congressional Committees, serves as an advisor to a wide array of policy makers at the State, Federal and International levels. And she is a proud graduate of the University of Michigan for both her undergraduate degree and her PhD in Economics, and she's also very dedicated and warm friend to the Ford School. So please join me in welcoming Dr. Gail Wilensky.

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0:06:56: Also with us today is Jonathan Cohn, in the center hotspot. He is a Senior National Correspondent at Huffington Post. He writes about politics and social welfare policy with great expertise in the area of health policy. He is the author of a book, "Sick: The Untold Story of America's Healthcare Crisis and the People Who Pay the Price." He has won numerous awards and accolades for his journalism and we're very fortunate to have him here with us today as well. So welcome to Jonathan Cohn.

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0:07:31: And we also have with us Dr. John Ayanian. John is a physician, professor of Internal Medicine, and also a professor here with us in the Ford School, professor of Public Policy. And he's the director of the University of Michigan's Institute for Healthcare Policy and Innovation. His research focuses on access to care, quality of care, and healthcare disparities. And he's currently leading an evaluation of the Medicaid expansion in the State of Michigan. Dr. Ayanian has served in key health policy advisory roles to State and Federal government is an elected member of the National Academy of Medicine. Welcome to Dr. John Ayanian.

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0:08:11: Alright. So we're gonna get to our discussion, and here's what our format will be today. I am going to ask our panelists some questions. We'll have a bit of moderated discussion, but then we'll turn to all of you, and we will have time for Q&A with the audience. I hope you all have the little white note cards at your disposal, you can write your questions on them, and some terrific Ford School staff will be collecting them and then bringing them down to our... Who I'll introduce later, our team who will be presenting audience questions to our panelists here. For the people who are participating with us online, welcome to them. And you are also encouraged to participate in the Q&A portion. You can send in your questions via Twitter using the #PolicyTalks.

0:09:06: Alright. Panelists. Alright. Alright. We're gonna start out asking you to think about where are we today? What are your thoughts on how the Affordable Care Act had been working through it's first years in the Obama Administration, and the changes and reforms that the current Congress and administration have made to date? We'll start with Gail on that and then go in order through as you're seated there. So, Gail?

0:09:35: I think the, hands down, most important effect that we have seen to date is the expansion in coverage, which you mentioned early on. This has been a challenge the United States has had, continues to some degree to have, and was only going to be ameliorated if there were proactive changes to expand Medicaid coverage to some of the poor and low income people not otherwise covered by Medicaid. And to some of the people who were not in a position to get employer sponsored insurance, either because their employer didn't offer it, they were self employed or entrepreneurial, or they chose not to accept it. As you've indicated, we have seen a substantial reduction, 2010 is a somewhat artificially high start date. It was very much when we were still on the throes of the recession. But it's close enough to indicate that we have seen a substantial reduction in the number of uninsured, that's a real positive. It looked as though we were seeing a slower growth in spending that some attributed to the Affordable Care Acts introduction. I was never convinced and I think there is enough indication now that most of the slow down, which was very helpful to have experienced, from 2010 to 2014, happened primarily because of the global recession.

0:11:25: And secondarily, because of the adoption of high deductible plans not just in the exchanges, but more importantly because it's much bigger, by many employers in terms of having an impact on healthcare spending. You can raise some other questions about potentially undesirable effects, but it has a real effect on spending. This became clearer when OECD put out information in the fall of 2015, that looked at spending worldwide from 2009 to 2014. And as significant a reduction as we in the United States experience during that period, it was actually slightly less than the average OECD country experienced during 2009 to 2014. Again, we were able to have a period of slow spending, good for us, that knocks down the base from which the growth is now reoccurring. It's a reminder that we have not actually resolved many of those challenges. Most interesting part of what has happened to date, despite the best efforts or at least efforts, I don't know they sometimes didn't seem very well thought through, of the Republican Congress to repeal, or repeal and replace, or repeal and modify the Affordable Care Act, there has been very little that's actually happened to date. Including either legislation that has been passed, or more importantly, coverage that has been reported.

0:13:18: Despite taking away some of the promotion money, the number of people in the exchanges is very modestly less than it had been, about 400,000 out of 11.3 million. That is really not very surprising because the good news or the bad news is, most of the people that went into the exchanges were those individuals that were very heavily subsidized, or who really, really wanted insurance and had been medically un-insurable before the Act. Those people are continuing to participate with heavy subsidies. They are mostly the under 250% of poverty line people, or people who are on the expanded Medicaid program, which is where the heavy lifting of insurance expansion has occurred. It is really in many ways the unsung hero of the Affordable Care Act. With a lot less drama, it's picked up the majority of newly insured. As best we can tell, it has done a good enough job that the rest of us haven't heard too much about it, which is usually not a bad metric to follow.

0:14:35: The bad news is the instability in the insurance exchanges that had been present almost from the get-go continues. Before the election, a third or slightly more counties had only one insurer. That is not improving. There has been substantial increases in premiums. Some people thought they would be one time. It was hard to make that conclusion on the basis of one point. One point does not a line or trend make. For most of the people on the exchanges, it was relatively irrelevant, because their subsidies are calculated in a way to pick up the premium exchange, the premium change. It's really the people who were outside of the exchanges that have been impacted negatively because of the increase in cost of the exchange. Now, it's not like the Republican Congress didn't try to destabilize them. I think for the most part, it has had surprisingly little effect. And in my opinion the relaxation of the mandate will also have minimal effect, I am not in favor of that by the way. If you guarantee that people with pre-existing conditions should not be penalized if they don't insure, or decide at some point they wanna become insured, you have to have some heavy-duty arm twisting incentive around to keep them in or you invite bad behavior and adverse selection. The reason I think it'll have almost no effect is because the people who are in are being heavily subsidized, and there is no real place for them to go that would make any sense for them to go to.

0:16:34: So while in principle it's dumb, bad policy, in practice I think it has very little effect. But it wasn't the only dumb policy that went on, Jonathan actually had quoted me early on before the Affordable Care Act was implemented, about some of the worries that I had. "Was the mandate tough enough?" The notion of guaranteeing people who are under 26 that they can stay on their parents policy made great sense until 2014, when at which point you could get subsidized insurance on your own. It was not such a bright-eyed policy idea after that, because it artificially narrowed the favorable risk pool that you would otherwise like to come in. And this is all part and parcel of an ongoing problem of how to try to get a broad risk pool so that you don't get only those who are the expected high users wanting to come in, or who almost bear no cost.

0:17:40: We'll have time I know to talk about some of the things I think need to happen in order to fix those. But my assessment is despite the efforts of I guess not very effective Republican in Congress, there has been precious little change on the Affordable Care Act in terms of participation, both by individuals and insurance companies. And I think actually the president is correct, the cost sharing reduction payments ought to be done by Congress, not administratively, that was always a hokey fix, and at least the one judicial ruling that occurred indicated that this was correct, it needed to be an appropriation and not an administrative expenditure.

0:18:33: That's great.

0:18:34: Gail and I have done panels and interviews like this before, and I'm a little disappointed 'cause usually we have a more contrasting points of view. And actually our 30,000-foot view of the Affordable Care Act is remarkably similar, until we get to the effects maybe of some of what has happened since the Trump presidency has begun. But my overview is gonna sound a lot like hers, so apologies for that. But to me, what is the biggest accomplishment of the Affordable Care Act? I actually think there are two. Number one is the coverage expansion, and I think it's important to remember that when we say so many millions of people got insurance, that's not just numbers, that's not just statistics, these are real people getting healthcare. We actually are getting data now that shows pretty conclusively that overall we are seeing improved access to care, overall we're seeing more financial security as a result of the... These things are hard to measure, the effects are not always as dramatic as you would like, but I think it's very clear that we have increased human welfare, we have protected people who needed protecting, and that's a really big deal on this scale, we don't do that a lot in this country.

0:19:47: The second big accomplishment I think is, I think the Affordable Care Act has changed the political conversation. It has moved the bar. It has changed expectations. It has changed public expectations of what the government, what our society, should provide to people in terms of health insurance. And that was actually not clear until the effort at repeal happened. It was only when the Republican Congress tried to repeal the Affordable Care Act, which had never really been that popular, and yet when they tried to take away protections for pre-existing conditions, when they tried to take insurance away from millions of people who had on Medicaid, there was an outcry and they failed. Barely. It's not that hard to imagine that debate having gone a different way, but I do think that's an indication of how expectations have changed. At the same time, it set expectations that the law itself has not met. We still have tens of millions of people who don't have health insurance. Lots of people who have health insurance cannot afford their medical bills even now. There are a lotta people who feel like they are worse off because of the changes of the Affordable Care Act. These are all failures, shortcomings, and these were all true at the end of the Obama presidency.

0:21:04: I wanna drill down carefully onto the marketplace that the non-group is 'cause I think that's not as Gail says, it's not the most important part of the Affordable Care Act, it's a portion of the Affordable Care Act, it's a tiny portion of the population with insurance, but it's where the most activity, where the most controversy is. To reminder, this was where you couldn't get insurance if you had a pre-existing condition. This is where if you bought a policy and you got sick, you suddenly discovered it had these huge gaps. And the idea of the Affordable Care Act was to upgrade coverage, make it available to everyone, make it more comprehensive. Of course that made it more expensive, so then you had to subsidize it and you had to have a mandate to make sure healthy people bought in. It was not a crazy theory. It worked in Massachusetts mostly pretty well, as well as these things ever work, and the idea was to replicate that. And if end of 2016, early 2017, you looked across the country, you found states where you had that. Not coincidentally, it looked a little bit like a blue-red political map. California, Rhode Island, tended to have fairly well functioning markets.

0:22:03: Michigan actually had a fairly well functioning markets for reasons that had to do with the idiosyncrasies of the state. And that's one thing you find if you study states, there's a lot of factors at play here. Michigan happens to have relatively cheap health insurance, which helps. But you had states like Tennessee or Iowa or Nebraska where really things were already getting out of control, where if you didn't qualify for those subsidies, the coverage was really expensive. And that was, again, I would call that a failure or a shortcoming of the Affordable Care Act, a product both of the way it was designed, policy decisions made by the Obama administration, also decisions made by state Republican officials who were hostile to it, decisions to not fund something called the risk corridors which was supposed to be to help insurance companies weather early losses. That was something that was done for... Demanded by the Republican Congress.

0:22:52: So that's where we were, 2016-2017. The Trump administration comes in, the Republicans have Congress. Obviously they tried, they failed, to repeal the law. They have taken a series of steps to weaken it. They've cut outreach money for enrollment, they cut off these cost-sharing subsidies, the individual mandate is now about to come off the books. I always say I don't think any one of these was all that devastating. I think with most of them you can find a small effect. For example, a lot of people looked at the numbers, they cut off the funding just before the end of open enrollment for this past year, and a lot of people looked at the numbers and noticed that usually there's a last-minute surge and that last-minute surge in enrollment didn't happen. And at the margins, that probably contributed to these problems.

0:23:38: When you add them all up though, I think what you do have is a situation where, in those states where officials are committed to making the program work, it's going to continue to work, they're going to take the steps to shore up their markets. Even in those states it's not perfect, even in those states they have problems. But where you have states where officials are not committed and not now being aggressive to really implement the law and really promote it to regulate the market in the way the designers imagined. I think your gonna continue to see this problem where for people who don't qualify for subsidies coverage is just gonna... It's become frankly truly unaffordable not just this is more expensive than I want but I just couldn't pay for this and that's a real problem and I feel like that's where we are headed.

0:24:27: Thank you. Dr. Ayanian.

0:24:29: So thank you Professor Lantz and Dean Barr for the opportunity to join the discussion today. As a physician on the panel I have to say every week in our primary care clinic here at the University of Michigan I'm seeing patients who are benefiting from the Affordable Care Act, either through new Medicaid coverage or qualifying for a marketplace plan that they can now afford, and sort of all the ways that Gail and Jonathan have described. And I think that's very important. We can look at the overall numbers. Over 20 million people now are covered that weren't covered back in 2010. That's a real advance, the biggest drop in the rate of un-insurance in the last 50 years in the United States, after sort of steadily increasing rates of un-insurance. I think it's also important to point out the equity effects of the Affordable Care Act, which have really been concentrated among low income, non-elderly adults, so primarily those between 19 and 64.

0:25:19: Earning less than 200% of the poverty level. For them, before the Affordable Care Act, the rates of un-insurance were up around 40%, and they've been cut in half. And also from a standpoint of racial and ethnic equity, as we think about Martin Luther King, the anniversary of his death today in this week. We've seen for Hispanic Americans who had rates of un-insurance over 40%, they've been cut in half. For African Americans who had un-insured rates of 20-25%, they've been cut in half. And for white and Asian Americans, they've been cut in half as well, just starting with a lower rate of un-insurance. So that means many more people are accessing care. And we're seeing for example here in Michigan when we look at the Healthy Michigan plan where coverage has been expanded, people who've gone without care for five, 10 years or longer, including dental care which is an important benefit that we've seen here in Michigan with the expansion of Medicaid, they're getting in for care, they're getting their chronic conditions treated, high blood pressure, diabetes, heart disease, lung disease, conditions where we know people are gonna be in worse, they're gonna function more poorly, be less able to work, if their chronic health conditions are not cared for. So that's in my mind the greatest accomplishment of the Affordable Care Act.

0:26:26: There's some other points that I would add to what Gail and Jonathan have said. We've seen it's, particularly for safety net hospitals and community health centers it's really stabilized their financial status. They were providing... Many of these organizations were providing high levels of uncompensated care what we call charity care. When we look here in Michigan the rates of uncompensated care for Michigan hospitals have gone down by about half from 2013 to 2015 as coverage was expanded and we've seen in areas like Detroit and flint and other low income communities that hospitals are able to increase their staffing they're able to provide more services and actually reach out to the community to bring people in who are newly covered and so I think that's an important benefit. The benefit's not just those who gain coverage but it stabilizes those organizations for people who either already had coverage through an employer or were covered by Medicare. Another important point it doesn't get a lot of attention with the Affordable Care Act, although it hasn't really slowed the rate of cost growth overall in the health systems as Gail pointed out, that was more a function of the recession within the Medicare program where there was a lotta concern about sort of whether we could sustain for a, particularly as the baby boomers aged into the Medicare program.

0:27:37: We've actually seen from 2009 when the Medicare trust fund was scheduled to run out of funds in 2017 with the Affordable Care Act both from a combination of raising some taxes on higher income Americans as well as taking some money out of the system some excess payments that Medicare HMO plans were getting where some of the cost growth for hospitals and nursing homes. We've extended the life of the Medicare trust fund by an additional 12 years after 2029 so that has real benefits for the whole population that relies on Medicare either as we get older turn 65 or become disabled. Two other points I point out is strengths I think it have benefited people with private insurance coverage is the elimination of exclusions for pre-existing conditions which was a big barrier for many people to get affordable coverage and then the elimination of cost sharing for effective preventive services so mammograms or colonoscopies or Pap test when indicated for the right age group.

0:28:33: People can now get those through either private or public insurance without out of pocket expenses that might have prohibited some people from affording them. So those are some of the big pros that I see with the expansion of the Affordable Care Act. Some of the issues that still remain unresolved it's not clearly slowed the overall growth in cost within our system and particularly one where I think a lot of Americans feel the pressure rising costs for prescription drug cost. Although it was called the Affordable Care Act it didn't sort of do a lot to really move the underlined trends in terms of cost growth in the United States. Some of that's for innovations in new drugs and devices things that we want to provide here in the United States and because we fund much of that research and development, the rest of the world benefits as well. But I think we have to come up with some better mechanism particularly for paying for new breakthrough drugs that may benefit a small part of the population but really can sort of grow out of control for private and public insurers.

0:29:35: Another issue that doesn't get a lot of attention is that while we've reduced the rate of un-insurance by about 20 million Americans, there's still large groups strictly undocumented immigrants or people who lived in the Unites States as illegal immigrants for five years or less don't benefit from the coverage expansion of the Affordable Care Act, so that probably represents about 10 to 15 million people who remain uninsured under the current system. And then lastly I would say... We've seen this law, the Affordable Care Act, I think of this law with nine lives. It's survived a couple supreme court challenges, many attempts in Congress to repeal or replace it which failed by about the margin of John McCain's thumb on one of the most recent attempts last summer. But we now have 18 states that have not expanded Medicaid and it's really a state by state struggle. 32 states have opted to expand Medicaid since 2014, but 18 states predominantly in the South and some in the West have still not have made that choice to expand Medicaid.

0:30:35: We're starting to see some states put this on their ballot for public's engagement. In Maine last November they approved Medicaid expansion through a public referendum, three or four other states are considering putting it on the ballot in 2018. And then we have states like Virginia that have very closely divided legislatures where they may be on the verge of expanding Medicaid. And so I think that's an important question going forward. And another thing we saw last summer with the Congressional attempts to repeal Medicaid and I know Gail has written about this that there was a sort of an outpouring of support from governors across the country, particularly republican governors in states that expanded Medicaid. Saying this program and the expansion has filled an important gap in our coverage for things like the opioid epidemic where a lotta states were using the new Medicaid money to fund expanded treatment for people with opioid addiction. And so a number of republican governors worked closely with their legislatures in Congress and in the senate to try and preserve the affordable character at least the Medicaid expansion for that exact reason.

0:31:38: Thank you. So you've all alluded a bit to concerns you have about what the state of affairs right now. But I wanna ask you all a bit more explicitly about what you think are the biggest most pressing problems given the current state of affairs. There's really no one who thinks the way that the United States does healthcare and healthcare policy and our current status quo is a very good system, thinking about healthcare costs, again, coverage, access, disparities. So, again, what do you think are the biggest pressing problems for the people of this country and their health and their healthcare? We're going to start with Jonathan on this one and then go to Gail and then John.

0:32:33: I think the big problem in the background that drives all of this, that I think probably all of us would agree, is this... Somehow we have to get the cost of care down. And that's a long term problem and a big project so I'm not gonna talk about that.

[chuckle]

0:32:48: We can talk about in the Q&A. I do actually have a nightmare, it's called Nebraska. Anybody from Nebraska here? Have I offended anybody? There's probably someone watching from Nebraska. Lovely state, great people, I've spent a lotta time there this past year. But the Nebraska insurance market is my nightmare. Nebraska is one of those states I was talking about before. For a combination of reasons, some of it having to do with the demographics, it's a rural state, some of it having to do with the policy decisions made by the people who run Nebraska, some of it having to do with the way policy decision is made in Washington both during the Obama administration and Trump administration, and the design of the Affordable Care Act. It is one of those states where the market for the non-group market has basically split into two. If you talk to people there, I remember I've spoken to people there. If you are subsidized, you don't have a lot of choice in insurance.

0:33:45: There's only really one provider in most places, but they do offer a couple of... Dirt cheap, dirt cheap coverage, particularly after the CSRs which kinda backfired in a weird way. You can get really cheap coverage, really good insurance, and you're golden. If you are above that subsidy line, so if you are above four times the poverty line, which for a family of four these days is about $100,000 a year, you're really in trouble. I was gonna say something else but this is a lecture, I won't use that word. The cost is just prohibitive. And what is happening now is that you think, "Well, what are people gonna do?" They're not gonna buy that insurance unless they can really scrape together the dollars and they have a very serious chronic disease, which of course makes the overall risk pool worse. Everybody else is fleeing. And what most of them are doing, and this has been going on for a while, is they're going into alternate plans that are out there and still legal and kind of work though the loopholes of the law. There's two in particular, one are the short term insurance plans which were originally created as this niche product to get you between jobs or whatever.

0:34:49: They were originally good for three months or couple months, the others are what are called Christian Sharing Ministries which are run by religious organizations and have a long history of going back to groups of small groups of people of like faith getting together to kind of share their medical expenses. What these have in common is they look almost exactly like the plans that were sold before the Affordable Care Act came, became law. You can't get them with preexisting conditions or they won't cover your preexisting conditions. They will have limits on benefits, they'll have big gaps, they might not cover full prescriptions, they certainly won't cover maternity. They frequently don't cover mental health. They are cheap. They are very cheap because they don't have to cover the sick people and they don't have to cover all these bills. So if you're healthy and you manage to stay healthy they're a pretty good deal. The problem is what if you're healthy and you buy one of these and suddenly you get sick. Then what happens?

0:35:48: So this is not a hypothetical, I actually met a couple, I wrote a story about them who had enrolled in one of these shying ministries. They read all the literature, they were conscientious consumers but the stuff is confusing. Didn't realize that if they got sick there would be a look back to see if they had a pre-existing condition, they end up in this big dispute where the insurance company found something from three years earlier and said, "Oh wait, this cancer you have was actually you had it the whole time and we're not gonna pay the bill." And they had to go through the whole thing. Now they did in the end get the bill paid, but that kinda thing used to happen all the time. The Affordable Care Act was supposed to wipe that out, but it's happening again and we're seeing this world come back the sort of substandard market, and is going to grow for two reasons. One is that states are discovering this and starting to make it easier. Nebraska's neighbor Iowa just passed a law under which the Farm Bureau's going to be able to offer insurance plans that are not insurance plans. So they're not calling it insurance, it's just a health benefit plan and because of that is not subject to the Affordable Care Acts insurance regulations and the insurance department can't regulate it.

0:36:58: But it covers your medical expenses, except it doesn't if you have a pre-existing condition and whatever. And then secondly, and this is where I think the mandate becomes an issue, which is that these plans had been out there for a while, kind of what was sort of holding back the dam on them was the mandate, 'cause you pay a mandate penalty, at least for the short-term plans, the ministry plans were always exempt from the mandate. Now without the mandate, there's more incentive to go into them. To be clear, Nebraska has a big problem, coverage was already unaffordable for a lot of people, but this is moving in a direction to make that problem worse and basically to recreate a market that, at least for the unsubsidized, it looks like it did before the ACA. And I think that's where we're headed in those states.

0:37:41: Okay, thank you.

0:37:43: Right assessment of where we are, wrong assessment of what's driving it. And let me explain why I think that. Jonathan talked about subsidies up to four times the poverty line, technically that's true. In fact, it's absolutely not true. If you look at who's been in the insurance exchanges since 2014, it has been 85% people who are below 225-250% of the poverty line. The reason you've got all of these offerings coming out is that you've had people who were above this, including 275-300% of the poverty line, 350, who were being expected to have the full, broad coverage that the Affordable Care Act required, except they were getting almost no subsidy. Well, of course they weren't doing that. The people who have been getting the heavily subsidized plans are gonna continue in there. The problem has been this was an inherently unstable dynamic that was put in place because of the way the subsidies run, and the requirements of the plans.

0:39:05: Most of the people who are fleeing to get either the short term plans, or the options available in the farm plan or its equivalent, are people who were not on the Affordable Care Act exchange. Those people were and continue to get heavily subsidized. Now that doesn't mean there isn't a real problem that's out there about what are we gonna do for people who don't have employer-sponsored insurance and that has its own issues, who don't get major subsidies, and oh by the way we have some real problems that are brewing because if you're a low middle-income person, twice the poverty line a little higher, the amount of subsidy you get when you go buy your insurance in the exchange is way more then the subsidy you get when you have employer sponsored insurance. And that is fundamentally unfair and likely to lead to its own instability. As economists like to talk about horizontal equity that is people who are at roughly the same income are to be treated roughly the same by the government. But they're not in this case, if you're just it to twice the poverty line 225%, 250% the fact that you don't have to count your employer contributions as income tax means basically nothing to you because you're not paying income tax at that level or a very little amount.

0:40:42: You do get some savings and not having to pay Social Security and you get some averaging that occurs because the employer is offering the same health care plan but it's nothing like the subsidy that people who are at 150 and 200% of the poverty line are getting. We've got to make some decisions about what are we willing to subsidize, what kind of plans do we wanna have offered to people, and this instability that was going on that Jonathan describes has basically been inherent in the Affordable Care Act since it was started, it is only playing out more dramatically. Now personally this notion that we were ever gonna repeal the coverage expansion was ridiculous. It had already been in place for three-and-a-half full years by the time this came up. There's absolutely no precedent in our history ever of having an entitlement and expansion of benefits in place for any sizable population for 3 and a half years and putting it away. And while we talk about and I don't want it in any way take away from the brave public stand that John McCain took.

0:42:01: I think there were several Republican senators. If there hadn't been three, the magic number needed to report Torpedo, the Legislation and the Senate who would've done so in large part because you had so many Republican governors who were so substantially in favor of the expansion and what it meant in the Medicaid Program. The question we really have to deal with is what can we do to try to stabilize these markets that will not be inherently unfair to the people right above them, right on the side of them. And its gonna get to some of the discussion that we have with regard to the Medicaid expansion. To me again, one of the questions is how can we make that transition between Medicaid and other kinds of insurance be more seamless, where we don't disrupt the delivery systems the way we do now. And what are we gonna try to do in terms of a trade off. It is not gonna be have the same extremely expensive benefit package that the Affordable Care Act is all the way up to four or 500% of the poverty line. I just don't... I think that the money is just gonna cost too much.

0:43:17: That doesn't mean we have to go back to the very narrow plans that we are seeing crop up in response to people who are unsubsidized, who are being said, "This is the only thing you can get under current rules." We shouldn't have been surprised. They were the very people who you heard on television. In 2014 and in the fall of 2013, when they got notice, people especially in their 50s, childless couple or couple whose children had grown up and gone away that were not going to be receiving a big subsidy 'cause they had $40,000 of income, hardly a wealth of money were gonna be expected to buy a very broad based benefit plan including many benefits they would never use, except they weren't gonna get any help paying for that. It is really what we're seeing playing itself out in a different way. Same issues. We have to come back and fix them.

0:44:23: Jonathan and Gail have, I think, covered the instability of the marketplaces very effectively. I'll touch on a different issue so we can move forward and get to the audiences questions as well, but briefly, to recognize that the Affordable Care Act was health insurance reform. It was not healthcare reform. And if there's sort of an unresolved issue in the US system of healthcare, it's how do we get greater value out of our healthcare system? And the Affordable Care Act took some initial, small steps. It created a center for innovation within the Centers for Medicare Services, what's known as CMMI, that's testing out some new demonstrations of how we might try to integrate care more effectively. We've started and always had a very fragmented healthcare system and that's a big part of what drives the rising healthcare costs that put us so far apart from the rest of the world in terms of what we spend. And we have... It's not just cost growth, but we have value stagnation. We're not getting the value for the dollars we spend on healthcare. I think, if our costs were growing at a modest pace and value was growing even faster, we would potentially accept that as a good use of economic resources. But oftentimes we see the cost growing and our life expectancy in the US has stagnated the last several years.

0:45:35: Infant mortality is still much higher than it should be and we have large burden of chronic disease that we're not really tackling. So I think one of the important issues is how we think about integrating healthcare and social services to address social determinants of health. I think that's something that the rest of the world does more effectively than we do here in the United States. Oftentimes, in the developed countries, the OECD countries, if you look at the combination of healthcare spending and social service spending, it's a lot closer in the United States to other countries. It's just we spend a disproportionate share of our resources on medical services and less on social services, affordable housing and transportation and home care services. I think that's one of the big unresolved challenges that I would highlight, is sort of where, as a country, we still have to go beyond the Affordable Care Act.

0:46:22: Great. Thank you. I'm gonna ask the panelists one more question and then we'll turn it over to all of you fine people. So those of you in the room who consider yourselves policy people, you know that we often try to imagine ourselves with the magic wand. So if you could wave your magic policy wand, my friends, what would be the one policy change you would like to magically make in regard... And we'll come back to... Let's talk about health insurance reform right now in the US. If you could wave that magic wand and today make one policy change in health insurance in the United States, what would you do? And we'll do John, Jonathan, and then Gail.

0:47:10: My magic wand would be very simple. Expand Medicaid in the 18 States that have not yet expanded it. And that would help millions of people, low income people with chronic illness who would benefit from the coverage, like we've seen here in Michigan and 31 other States.

0:47:27: That was easy. Alright.

[laughter]

0:47:29: 'Cause it's magic.

0:47:32: So how powerful is my magic wand?

0:47:34: It's really, really powerful.

[laughter]

0:47:38: Can I go back and change the outcome of the basketball game? No?

[laughter]

0:47:45: That would improve the mental health of Michiganders.

0:47:46: It really would. It really would.

[laughter]

0:47:48: If it was an all powerful magic wand, I'd go back to 1932 and start a national health insurance system then we have something to look back one of these well functioning, European...

0:47:58: I didn't say you had time travel powers, but okay.

[applause]

0:48:02: Lacking that power, and since John already talked about the Medicaid expansion, I would boost the subsidizes, plain and simple. I think what Gail's describing it, I think we were both describing the same dynamic. Where basically, if you're either unsubsidized or not subsidized well, and that was an important distinction I should've made. If you're basically above 250% of the poverty line, particularly though if you're above 400% of the poverty line, you're not getting much assistance. That is a root cause of the instability, both baked into the cake, made worse by various decisions along the way, I would argue. You can deal with that in two different ways. You can make the insurance package less generous, so that it's cheaper that way, or you can say, "That's actually what we wanna provide people, so we need to give them more money." There's a trade-off here, it's... And my magic wand is not gonna make the trade-offs away. It's more money, but you make the subsidizes bigger, more generous, and you try to make it a better deal for those people who don't find it to be a good deal. So, that would be my three magic wands.

[laughter]

0:49:10: You have to, again, use, economist term, focus on both horizontal and vertical equity. That means you've gotta be mindful about how you treat people at the same income level. The issue that I talked about for low-middle income people, who are treated dramatically different by the government, depending on whether they get a subsidy from the exchange or their employer-sponsored insurance. And you have to be more mindful about what happens as you go up the income scale, so that you don't find people who are treated dramatically differently in unintended ways, depending on either how they access insurance or where they're living. And that we need to take... This has been a long term issue in the US for people who are not poor low income, who don't have employer-sponsored insurance. With the incredible inefficiency of having this tax exclusion, should cost the government $250-270 Billion a year, and could be spent in a much more rational way. So trying to sort out both having the slow-down on the tax subsidy as people have higher incomes, having it be available for middle income people who are working but not getting employer-sponsored insurance, and therefore have to use after-tax income.

0:50:55: And having the rational transition between fully funded Medicaid and what happens when you cross whatever line. So, being much more mindful both of the movement up the income scale and treating people more comparably who are at a similar income level, but who are either getting employer-sponsored or not insurance. It would take care a lot of the non-healthcare delivery issue challenges. Doesn't mean it'd be easy, but I very much agree that the real problem was that we look to the Affordable Care Act as being healthcare reform. It never was. It was insurance market reform for the individual market, and an expansion of coverage by subsidizing some poor and low income individuals. Important, not trivial, but actually not the hard problem.

0:52:01: Thank you. Alright. So now, we're turning to all of you. Seen a lot of the questions come down already on note cards. And again, for those who are with us online, you can tweet in your questions using the hashtag #PolicyTalks. We have two terrific Ford School students who are going to be asking the audience questions, and they're going to be assisted by my friend and colleague, Professor Rick Hall, here at the Ford School. Our students are Jeff Gam, who is graduating in a few weeks, yay! With his BA...

[applause]

0:52:36: His BA in Public Policy and a minor in Business. And Jeff's moving to Madison in a few weeks to work for Epic, work on healthcare information technology. And we also have with us today Dr. Jenn Villavicencio, who is a Master Public Policy student with us here at the Ford School. She's also a practicing Obstetrician-gynecologist, in her spare time. And we're delighted to have both of you here today to help us with the Q&A portion. Thank you.

[pause]

0:53:14: Can y'all hear me? Great. Thank you for having us. I'm Jenn, different than Jeff here.

[chuckle]

0:53:19: Thank you for all of your questions from the audience as well as from Twitter. We've gotten some really great ones and we've had to make some hard choices. Our first one for the panelists are going to be about Medicaid work requirements. The question reads, "CMS, or the Center for Medicare and Medicaid, has issued guidance for Section 1115, waiver proposals to implement work requirements and community engagement requirements. CMS has approved work requirement waiver in Kentucky, and many other states have put in their requests for that. What are your opinions about work requirements for Medicaid beneficiaries, both traditional and expanded Medicaid?"

0:54:00: I can start us off, we're actually gonna be debating, in the coming weeks and months, a potential Medicaid work requirement here in Michigan. There are a couple of bills in the state legislature now that are under consideration. As the question mentioned, we've seen work requirements approved in three states: Kentucky, Indiana, and Arkansas. And I think, here's an example, and it's, if we turn the clock back to 2013 when Michigan was deciding whether to expand, we had a Republican state senate, Republican house, and Republican governor, and made decisions in the legislature though bipartisan negotiation and agreement to expand Medicaid with certain stipulations that required approval from the federal government, cost-sharing and financial incentives for healthy behaviors, among others. And this is another example where I think work requirements, at least on a trial basis, I think could be something that is worth considering in Medicaid programs.

0:54:58: I think if we do institute them, we should start with the expansion population, the traditional Medicaid population that existed before the Affordable Care Act, typically covered low-income elderly, disabled, children, pregnant women, groups where the likelihood that they're not working but easily could work is gonna be relatively low, whereas, we have actually data now from our evaluation of the Healthy Michigan Plan here in Michigan that among the expansion population about half of the adults in that program are working, about a quarter of them probably can't work because they're either in school, or they're caregiving for a disabled household member, or they have a serious health condition, so it prevents them form working. So, all the discussion on work requirements may be sort of a lot of political angst for a relatively small part of the population. As we see Michigan, maybe only about a quarter of Medicaid enrollees. We'd even be potentially subject to the Medicaid work requirements depending on how the exemptions are arranged.

0:55:58: So I think if that was something that we need to sort of consider in order to keep this coverage that we have for millions of Americans nationally and about 650,000 in Michigan, it really will come down to how do you implement it. Because what we don't want is people to lose their coverage because they're not working; and in fact, they're not working because they have diabetes, or they've had a prior stroke, or they have chronic lung disease. And you take away their coverage, and now, they're even worse off, and they rely on emergency departments at that point, lose their access to primary care. So I think that will really be the question: Do we have sufficient exemptions for in-hardship considerations for people with severe functional limitations or chronic health conditions? Do we provide job training and job coaching to get people connected to work if we're expecting those, a condition of their Medicaid coverage? And do we evaluate how this plays out? 'Cause I think one of the big concerns is it could be very large administrative cost to track all the people who are subject to work requirements, for relatively modest financial savings for the state, if people are moving out of Medicaid and into jobs that offer health insurance.

0:57:03: I don't think it will have much effect, but I think it's a very important provision that may bring in some of the 18 states that have thus far not been willing to participate in the expansion. The reason I don't think it will have very much effect is because, as John has indicated, many of the traditional Medicaid populations, they are not people who are likely to be able to work. They're dependent, they're old, they're disabled, they're pregnant women. It's more in the expansion population. And the numbers he quoted are the ones that I've heard guessed at in general, which is about half the population works, and of the population that doesn't work, some number, maybe half, could potentially work, and some number is not likely to. If you look at the actual Medicaid waiver requests, they are not just work effort. They are either being employed, looking for work, doing community service, having job training, or some other activity of that sort. That is not a particularly unreasonable set of requirements to have on the books for people who are not disabled, pregnant, unable to work for various reasons. You would not like to ever invoke taking away someone's Medicaid coverage. You would like to use this as a big stick to get them to act somewhat differently than they may be.

0:58:46: My view, however, is much more practical. There are several states that have thus far not expanded their population, that have indicated, as a result of CMS being willing to consider this, they will now reconsider. Virginia got within one vote of the Medicaid expansion. Kansas has talked about re-asserting their ability to expand. For me, there is sometimes a fundamental failure to understand that in some states, the notion of not expecting people to either be working, or in training to be working, or have some other clear reason that exempts them from an expectation of work is not tolerable with regard to an expanded public program. So I have encouraged some of my friends who are very much against this provision to take a deep breath and recognize this may be the one way to get 18 states who didn't respond to a 100% Federal money into the fold. And if that's the case, it's okay because there are a multitude of outs as to why the negatives might not occur.

1:00:13: As I've said, I would hate to see, both at a practical level and a medical level, it ever get invoked, because the rules require that hospitals have to take care of medically-unstable individuals. So nobody's gonna be better off by actually yanking the Medicaid coverage, since you can't keep, you don't wanna keep, people out of the emergency rooms. But that would just be terrible for them and terrible for us as the payers if that happened. It's really a club to try to convince the people of your state that those receiving this expensive service are doing their share. Some states, that's not been necessary; other states, apparently, it's a much bigger deal.

1:01:03: And so, I'll just... Just to echo what something Gail was saying, which is one of the interesting things about this, I think she's absolutely right. This may be the ticket to get a bunch of states that would not think about Medicaid expansion into Medicaid expansion. And if you're thinking in practical terms, that's a big deal.

1:01:20: You get old enough, you start thinking in those terms.

[laughter]

1:01:23: You're talking about states the size of... If you could imagine... Look at the states that are out of the Medicaid expansion. You're talking Texas, Georgia, Florida. We're talking in the millions here, so that's a big deal. I also think what she said about the... The sorta moral argument here is something that I think people in rooms like this sometimes don't appreciate, that is that the policy arguments against this work requirement, there's a long list of them. It doesn't work well, it's not a lot of people, doesn't encourage people to get work, they're expensive to administer. But you talk to people and there are a lot of people who are angry like, "Why is someone getting free medical care and I'm not?" And that work requirement means a lot to them. So that's there, whether you like it or not. The flipside is that, number one, in reality, what is going to happen, and I think what worries a lot of the progressive advocates, is in this world of low-income work, it's not even the work requirement; it's the paperwork requirement to satisfy the work requirement. It's the number of times you have to show that you're doing these things. These are complicated.

1:02:34: And again, in this world, you're dealing with a lot of people who have... Maybe they have mental health issues, they have disability issues that are not qualifying them for disability payments but make it hard for them, they have transportation issues. It's going to be hard. And everybody knows that when you impose these kind of requirements, one thing that happens is that you pare the roles down just by sort of introducing that hassle. And some of these people, a lot of these people, are the ones who you really don't want to go without health insurance 'cause they're really the ones who, if you can get them in for the preventative care, and you can get them into the mental health, really stand to benefit from it. So that is a sort of moral argument or practical argument, whatever you wanna call it, on the other side. And so, this is a complicated question, if you're strategizing or whatever, but there's a lot going on here.

1:03:23: Awesome. So my name is Jeff, again, nice to meet you all. I'm a senior here at the Ford School. And actually, in the next few years, I plan on joining the University of Michigan School of Public Health, Healthcare Management and Policy program, so I hope to see you in a classroom one day. [chuckle] So Gail, you mentioned in your discussion that there's never been a precedent for repealing an expansion of general social policy. And my immediate reaction, the reaction to some of the notes from our audience, was that we weren't so certain 'cause it seemed like a new precedent was very close in coming. And so, the question that we have from the audience here is, is this reversal in the historic trend towards expansion, is this a blip or is this something that we're going to see more long-term in terms of rising un-insurance again? And do we see populations or groups, more of them being covered in the next 10 to 20 years, or do we expect the potential increase in un-insurance to increase instead?

1:04:15: Again, and as taking a longer view, there has never been a takeaway of a benefit, and I don't think you will see it here. My view had been, if 2014 came and went, that was when the Medicaid expansion and the subsidies took effect, it was going to be there more or less forever. Although, changing something about the distribution or the shape, which may well happen in Medicare... That, by the way, the looming crisis is not the individual insurance market. It is a problem, it's unstable, it's not gonna be easy to fix. The looming crisis is the doubling of the population on Medicare for a program that is not currently set up to fund all of the promises with regard to healthcare that have been made. And you ought to be most worried on it because it is not the people who are close to retirement, it's not the people who are over the retirement age. It's the people who are coming along the line, and that is gonna be very serious issue.

1:05:30: I don't see us going back and having large numbers of poor people without insurance coverage. There is debates about, should Medicaid stop at 100% or 135%? I'd actually like to let more people buy in to Medicaid with their subsidy dollars. It's a very narrow network, but it's a broad package, and it has gotten the job done because both the clinicians providing services and the people who are on it have different expectations than the people who have been typically in either individual or employer-sponsored insurance. And it has worked in a much more stable way.

1:06:13: I don't see us going back, but we haven't resolved this issue about what it is we wanna stabilize, what our vision is that people who are primarily being subsidized should get at whose expense. You don't hear the kind of angst, or not very often, about people who are on Medicaid who are getting a fully-funded package of benefits but take narrow networks to new definitions. The question that we haven't resolved is, how do we view the population that is somewhat above that? And it's because we really haven't been willing to have that honest conversation with this. I don't think we're gonna take it away, but the question about what that insurance looks like, and at what point do we try to rationalize the kind of subsidies that happen as people go up. The people who have really gotten the short end of the stick are unfortunately the people who typically get the short end of the stick. The middle, the slightly middle plus, middle to higher income, but only not in what most people think about higher income in the statistical sense, the $300,000 to $400,000... 300% to 400% of poverty line family. The people who we are talking about between $50,000 and $100,000 a year for a family of four. We need to be more honest about the numbers of people that are there, and what happens as you continue up. So we haven't had that discussion, but we are not going backwards. It's just not gonna happen.

1:08:11: Thank you. We're gonna take a question from Twitter, and add a little bit from the audience. The question from Twitter, we had quite a few different questions coming in about insurance prevision structures. And so, the question from Twitter is, "What will be the role of employer-based insurance in the future? And we'd also like if you could comment on the single-payer health system as well, and which one of those you see being the most useful in this country." And if Dr. Ayanian, if you could answer this one?

1:08:42: Sure. One of the reasons the Affordable Care Act was so complicated is that it was not a government takeover of healthcare. It was built on the foundation of employer-sponsored insurance, and the understanding that many Americans who have employer-sponsored insurance may not be totally satisfied with it, but they're satisfied enough that they don't wanna give it up, and are very uncertain about sort of moving to a single-payer system. So I think the challenge is, even though as Jonathan was saying with his magic wand, if we were to start from scratch, we might build a single-payer system, or predominately, a government-funded system, like most other countries have done. It's very hard to get there politically in the current environment where most voters... And it's actually been tested in a few states where there've been ballot referenda, attempted to try and move to a state-wide single-payer system. And there either hasn't been the support, or in the case of Vermont, they tried and couldn't make the finances work. So it really... It may only be able to work at a federal level, and right now, the votes aren't there, I think, in the population or in Congress to move in that direction. So then, we're left saying, "How can we make the employer-sponsored system more effective?"

1:09:49: Certainly, we have generous tax subsidies, the fact that most of us who have employer-sponsored coverage get that coverage through pre-tax dollars. And that goes back to World War II when there were wage and price controls, and the only way that employers could give an extra benefit to employees was by giving them tax-free health insurance. And at that time, it was a small number of people, and it was inexpensive, and it's grown beyond anybody's expectations. So most economists... I'd be interested in Gail and Jonathan's thoughts. Would say, "That tax subsidy doesn't make a lot of sense, but how to take it away politically is a really thorny problem." And I think we... And it's really making people more educated and informed about their own health choices, both the personal choices they make, and the societal options that we give people to live healthier lives, as well as sort of what happenes when they start using the healthcare system. And do they have enough financial incentive to use it wisely? Oftentimes, that's very uneven, and we see clinically that there are a lot of people that overuse healthcare, and a lot of people who underuse it. And it's that mismatch of resources and needs that is one of our biggest problems.

1:10:56: I don't think we'll take it away, per se. We could certainly target it better. We could have it be graduated. And this notion of trying to be mindful, not so much to have exactly the same subsidy for people who are inside or outside the employment world, but to have such drastically different levels of subsidy for people at the same income level, really is problematic. It leads to a bad dynamic as people try to go to where the higher money is, and it's just unfair. To me the question with regard to a single payer is it's a political values issue. How much power are people willing to transfer to the Federal government, which at least, to date, has been not that much, not 17% of our GDP. It has grown in a variety of ways in terms of the government role. But people need to understand it's very different to say government-funded as though this were all one whole monolithic system. It's not. It's a whole set of different kinds of programs with different levels of control.

1:12:17: So to me, the question has been, "What can we do that is stable in an environment that is as large and diverse as this country, that will be politically acceptable to the country over some period of time?" And ultimately, if that's not where you're at, then you're not in a stable position. And unfortunately, it's not where we were at with the Affordable Care Act. It was just astounding to me that Republicans, who were so politically successful in beating up Democrats for having made this major change in social legislation with a single-party vote, got in power and turned around and tried to do exactly the same thing. It's like, "What part of this outcome did you think could possibly be different if you had been able to succeed? If you had driven this repeal and replace with a single-party vote, you would have just produced the reverse dynamic of what you've gone through for the last six years." I am still left shaking my head about what part of that perfectly obvious message are we having so much trouble getting across. So we will have to do something that works for us. It's not gonna look like what looks somewhere else. I just don't think so.

1:13:52: This next question is actually for Jonathan. So you'd mentioned in your discussion as well, if you could wave a magic wand, first, you'd go back and change the outcome of the basketball game, which we applaud you for. You also said that you'd go back to the early 1900s and you'd institute a national insurance market. And so, the question from the audience that we have is, in discussions about the Affordable Care Act, we've mentioned a couple of times how, ultimately, this was health insurance reform. And so, how far can health insurance reform take us without accompanying increases or changes in social service?

1:14:22: Far can health insurance without changes in social services?

1:14:25: Social services or more underlying values within the healthcare system beyond just insurance markets.

1:14:30: Ah. So I feel like you can answer that in a couple of ways. Health insurance reform, basically, is giving people insurance, and it doesn't change the way we deliver healthcare. I always thought, to be fair to the Affordable Care Act, and to be fair to the Affordable Care Act's architects, they said all along they were actually trying to do healthcare reform. They were actually trying to drive the system in a different direction. And I would say there was a lot in the Affordable Care Act that was supposed to do that. The reality is that by the time you've made all the compromises, and you scaled back, it was a lot of small, small steps. Now, I for one, am not totally ready to give up on all those small steps. And in fact, you see little springs and signs that maybe this step's gonna work, but it was always gonna be a very long-term project. Look, this healthcare system looks like it does because it's evolved this way for almost 100 years now, basically. It ain't gonna change in a year, it's not gonna change in 10 years. Driving that change is really, really hard. You can do it... There are ways to do it more aggressively, and I would hope that we would continue to move in that direction. But there's a reason...

1:15:53: One of the things I always try to remind people, it's very easy... And this is more sort of directed to people that supported the Affordable... And obviously, the people that never supported the Affordable Care Act never supported it, and that's their position. A lot of people who did support it, very disappointed in the result and feel like, "We could've done X, we could've done Y." And yes, it's very easy to imagine a law that would have worked much better; I can imagine one, you can imagine one, you can imagine one. But there's this thing called the United States Congress that had to get through. And we remember the thumbs down from Senator McCain. Please take your time machine, go a little further back to 2010 and 2009, and you wanna talk with the nine lives. That thing seems so close to collapsing so many times, it was barely, barely, barely they got it through Congress, really pushing as hard as they could on... You can argue in retrospect, "Well, if you hadn't pushed so much here, you would've... If you hadn't pushed so hard to do X, you could have gotten Y, and Y would've been better." That's a totally reasonable argument. "You could've been taking more chances." But it's hard to do this politically. Any kind of change is hard to do. So I hope we'll get to the point where we change healthcare more, but it's kinda hard to do.

1:17:08: I think the person asked, actually, the wrong question. I think what they should have asked, or what they meant to ask was, "Can you improve health by just expanding insurance?" And I think the answer is, either insurance or access to healthcare is a necessary, but not a sufficient provision in order to improve health. There's a lot about health outcomes that is dominated by non-medical factor events, public health, nutrition, education, employment, other opportunities. And that was really going to the comment that John Ayanian had raised. We spend twice as much on medical care as we do on social services. Most of the rest of the developed world has reversed the ratio, spends twice as much on social services than they do on medical care.

1:18:10: I think we're gonna find it hard to increase much in the way of social service spending until we can slow, dramatically, the growth on medical care. There's some hopeful signs. The CHRONIC Care Act was passed that will go into effect in 2020, which begins to allow a lot more flexibility in the Medicare or Medicare Advantage program in terms of what can be included under the healthcare budget, relative to the traditional, very narrow definitions. The Medicare rule that was released two days ago started moving in that direction. And a number of private payers have moved out, either in Medicaid or in their private insurance to try, at least, to make linkages with Meals on Wheels or housing assistance or other social services that they understand will be critical to improving the health and well being that go beyond medical care. So I think there's increasing understanding that improving health is not just about healthcare, and for many circumstances, it's least about healthcare. Although at moments in time, it's, of course, all about medical care.

1:19:31: Thank you. I regret that we are out of time today. I wanna thank you all so much for coming and participating. We have a reception out in our great hall, and our panelists will be out there. So there'll be a little more time to engage with them. But again, thank you all for coming. And please join me in thanking our distinguished guests.

[applause]