Experts will discuss the design and potential benefits of state-based single payer health insurance systems along with their economic and political challenges. September, 2024.
Transcript:
0:00:01.5 Dr. John Ayanian: Good afternoon and welcome. I'm Dr. John Ayanian, the director of the Institute for Healthcare Policy and Innovation here at the University of Michigan, which includes more than 700 faculty experts from across our university. I also serve as the Alice Hamilton Distinguished University Professor of Medicine and Healthcare Policy at the Medical School, the School of Public Health, and here at the Gerald R. Ford School of Public Policy. The United States is the only high income country without a system of universal health insurance coverage. As a result, we have the highest rates of un-insurance among all high income countries, estimated to be 3% for children and 11% for adults under age 65. In 1945, Michigan Congressman John Dingell Sr introduced a universal health insurance coverage bill. His son, John Dingell Jr, who was the longest serving member of Congress, introduced a similar bill in every Congress starting in 1956 until his retirement in 2015.
0:01:08.0 DA: And he was a key sponsor of the Affordable Care Act signed by President Obama in 2010. The current representative of Michigan's sixth District, Debbie Dingell, has sponsored legislation to expand health insurance coverage, keeping the idea of universal insurance on the national agenda. In 2023, she joined a coalition of legislators who introduced the Medicare for All Act in the US House and the Senate. In addition to a long history of national proposals for universal health insurance, many state legislatures almost half have introduced proposals for major health insurance to perform, including single-payer systems. And this is the topic of our discussion today. I'm very pleased today's health policy talk on state proposals for single-payer health insurance systems with a focus on policy, vision and design, along with a frank discussion of some of the serious challenges these proposals face. Our discussion is made possible through the generous support of Martha Darling, who is with us in the audience today, and Dr. Gil Omenn. Thank you Martha and Gil for your generosity.
[applause]
0:02:25.0 DA: So in this policy Talk, experts will discuss the design and potential benefits of state-based single-payer health insurance systems, along with their economic and political challenges. Our esteemed panelists include leaders of single-payer insurance proposals in three states. First, we're pleased to welcome Michigan State representative Carrie Rheingans, who is serving her first term representing the 47th House District, which includes parts of Washington and Jackson counties. She brings to her public service, prior public health policy work and her University of Michigan education, including Master of Public Health and Master of Social Work Degrees. Next, we welcome Ohio State representative Dr. Michele Grim, who's serving her first term in the Ohio State Legislature, representing the 43rd House District. She holds a doctoral degree in law and public policy from Northeastern University and has worked in government, public health, nonprofit healthcare and university research. She served previously as a member of the Toledo City Council.
0:03:30.2 DA: And our third panelist is Robin Lunge, who is over, is serving in her second term on Vermont's Green Mountain Care Board. This state board oversees proposals for hospital and accountable care organization budgets, insurance rate requests, and healthcare capital projects that require certificates of need. With a JD degree from Cornell Law School, and a master of Healthcare Delivery Science from Dartmouth. Robin has served as a state staff attorney for the Vermont Legislative Council and a senior policy analyst at the Center on Budget and Policy Priorities in Washington DC. And finally also joining today on the panel is Ford School professor and health policy expert Paula Lance. She's the James B. Hudak Professor of Health policy at the Ford School and Professor of Health Management and Policy at the School of Public Health. Over her career, she's applied her training in demography, epidemiology and policy analysis to a wide range of issues related to healthcare, public health and health equity.
0:04:32.7 DA: You can read more about our four distinguished panelists in the program. For today's event, I'll be presenting some questions to the panelists. We'll also have time for questions from the audience. For those here in person, please use the QR code on the sheets placed throughout the room to submit a question. If you're watching online, the question link can be accessed on the event page or in the event description on YouTube, LinkedIn, or Facebook. Ellie Bi, Ford School MPP student and the Rebecca Copeland scholarship winner will assist us with the Q&A portion of the program. So after the formal part of the program is finished, we invite you to stay to chat more for those of you here in person, to chat with the panelists and enjoy some light refreshments right outside. So let's get started. To begin, it would be great to have each of you on the panel provide a brief historical overview regarding proposals for single-payer health systems in your state. Let's start with Vermont which passed a single-payer bill in 2011, but it stalled before implementation by Governor Peter Shumlin in 2014. So Robin, could you give us a brief history of the single-payer health system in Vermont? And then we'll hear from Michele and Carrie.
0:05:47.2 Robin Lunge: Great, thank you very much and thanks for having me. So I worked on Governor Shumlin's single-payer proposal, including the legislation as well as the implementation. I was his director of healthcare reform. So Vermont has a very long history of expanding coverage through Medicaid programs to cover, have near universal coverage for kids through a program we call Dr. Dinosaur. And prior to the Affordable Care Act had reached a relatively low uninsured rate, but there is a concern about rising costs of care, efficiency of administration and other issues that frequently come up in the context of health insurance costs. And so Governor Shumlin ran for governor on trying to do the first state-based single-payer system. We like to be the first in Vermont for various things. So we passed the bill in 2011.
0:06:45.4 RL: There's a lot of excitement and energy around that. And what the bill would do is create what we call Green Mountain Care, which would be coverage, healthcare coverage for folks because they were Vermont residents and also for employees of Vermont businesses, which I'll put a little asterisk there 'cause that's an important distinction in our program. The benefits would be comprehensive, so very good coverage. Vermont has a lot of insurance mandates, so our insurance programs are very rich. We wanted to make sure that people didn't lose coverage with a transition. And also a generous coverage in the sense that there was some copays in co-insurance, but not not high copay. So it was sort of the equivalent of the state, one of the generous state employee plans, which is a plan that many Vermonters, if they don't have it, wish they were state employees so they could get it.
0:07:43.7 RL: The goal was really to find new funding sources and replace the private financing going into healthcare. So really replace insurance premiums with taxes. So as has happened many times actually in Vermont, this is our third run at single-payer. The first time we actually passed a bill we ran into problems when we hit the tax plan. So the tax plan that we landed on was to do a payroll tax on businesses to replace the amount of dollars coming from businesses currently in the insurance system. And the way the numbers worked out, that would be about 11.5% payroll tax. So going from zero to almost 12%. Now for many businesses, if they had very rich coverage or older workers, they were paying 20% of their payroll. So for them it would've been great. But Vermont is a state of small businesses.
0:08:40.8 RL: 90% of our businesses are under, have under 50 employees. And so for those folks, they were maybe paying 5%, 10% or nothing for insurance. So it became a challenge for how do you roll some people down and some people up to this new tax rate. So winners and losers, you'll hear as we continue the conversation are a big theme for me. And then we would also subsidize or pay for the plan with a income tax that would be between zero and 9%. And that would be a special income tax that we called a public coverage premium. So with the numbers at that level, the governor decided that it really wasn't feasible at that point to move forward with the financing plan. And so he did decide not to continue in 2014. Since that time, Vermont continues on the healthcare reform journey, we're focused more on payment reform and delivery system reform, how to make our health system more efficient.
0:09:41.6 RL: We've had very low uninsured rates since the Affordable Care Act was implemented at about 3% and less than 1% for kids. So I think that is partly why our efforts haven't been focused on coverage. But we are, we currently have an agreement with Medicare in Vermont to participate in the delivery system reform. And that agreement ends at the end of 2025. So we're looking at a new proposal Medicare has put out for states called the Ahead Program, which includes a hospital global budgeting system, which is not a big stretch for us 'cause we already have a regulatory system for hospital budgets. So I will end there and make sure others have enough time, but happy to answer questions later on in the program about the contours of our program. So thank you.
0:10:27.8 DA: Thank you Robin. So now we'll turn to Michele in the story in Ohio.
0:10:32.1 Dr. Michele Grim: Yeah, no, thank you for having me. So the story in Ohio spans a few decades. There have been some legislators in the Ohio house and Senate who have proposed single-payer bills, I think since the 1980s. Bob Hagen, who's a former state senator, he introduced bills when he was in the house and the Senate along with my joint sponsor who is represented Michael Skindell. He's been, he's introduced the Ohio Healthcare Plan 11 times. So 20, about 22 years. 'cause our session, our GA's are every two years, so 22 years at least. And then more with Bob Hagen. So he is retiring this year, so he wanted to pass the torch on to a freshman. So I am excited to have that torch to continue introducing legislation around single-payer healthcare 'cause it is important.
0:11:46.0 DG: I think we were very lucky to become a Medicaid expansion state early on. Governor Kasich did something right. So, but what the Ohio Healthcare Plan would entail is that it would fund every Ohioan through a single public fund and it would be a free choice of providers and fully covered for necessary services. And that includes vision, behavioral health and dental. No copays or deductibles, of course, covered regardless of income or employment. And then 91% of Ohioans would not see their taxes increased. The plan would be administered under the Ohio Healthcare Agency that would operate under a board, so the Ohio Healthcare Board. And we recognize that the insurance industry does have workers that would be displaced. So we have a plan for those workers. If they were displaced under the Ohio Healthcare Plan, they would be able to work for the Ohio Healthcare Agency. So that's kind of the history with that. I think that Ohio benefited from the ACA, but we still have a lot of work to go. And so I think that you're gonna hear from other folks on their plans and I'm really excited to hear about that.
0:13:14.5 DA: Thank you. Now we'll turn to Carrie to discuss the Michigan experience.
0:13:18.0 Carrie Rheingans: Yes. So you heard the long history of federal Medicare for all style plans with our former congressman, Dingell the senior, Dingell the junior, and now Debbie Dingell has been involved. So that's at the federal level. But at the state level we have had a Ann Arbor representative Perry Bullard in the '90s, 1991. He introduced Michicare, a plan for single-payer healthcare in Michigan and had a few co-sponsors and it never really went anywhere. Fast forward to the next century and at the time there was a gubernatorial candidate that put out a plan for Michicare, which would be single-payer that was kind of more driven out of the executive branch. And then since then we've had Ann Arbor's state rep, Yousef Rabhi also introduced MiCare, which is what he called a single-payer plan for the state of Michigan.
0:14:13.2 CR: And he introduced it twice and it did not get any hearings or votes or anything. This year we picked up former rep Rabhi's bill and reintroduced that in Michigan we have term limits. So he was limited to three, two year terms. The term limits have since changed. I am operating in my first term under a potential 12 years in the Michigan House of Representatives if I so choose, and the people still wanna hire me. So our bill that we reintroduced, we didn't make any changes from what rep Rabhi had introduced before. Since we have been doing town halls across the state, there's a lot of changes we will be making before we reintroduce it next term. It would create a MiCare board, which would then oversee a fund called the MiCare Fund. And the MiCare fund would be filled with federal dollars, state dollars, which would come from some taxes.
0:15:04.6 CR: And of course it would accept donations if anybody wanted to donate to it. And then those funds would pay for the necessary healthcare of any Michigander who has been here more than six months. And it would cover things like basic healthcare for physical health, but also behavioral health, dental care, hearing, vision. And we are very aspirational. We put that we would like to cover long-term services and supports, which is, as many of you may be well aware, the most terrible part of our healthcare system today in the United States. So that is where we are today. Our bill that we introduced last summer has the most co-sponsors it's ever had in Michigan, and we introduced it in the summer. So we didn't get a chance to talk to everybody, but I think when we reintroduce it in the future we'll have even more co-sponsors.
0:16:00.4 DA: So thanks. So now I'd like to turn to each of you and we'll start this question with you, Carrie. What motivates you to work on and advocate for single-payer legislation? What do you see as some of the potential benefits and positive outcomes that could come with this major health system reform at the state level?
0:16:16.9 CR: So I think you know, Michigan is a large state. We have 10 million residents that would be considered a very large group for health insurance coverage, right? The risk of the health conditions of that large of a group would be spread so thin across such a large group of people. It would be really efficient to have one payer that is contracted with all the providers in the state. The providers wouldn't have to negotiate contracts with multiple payers. It would really reduce that administrative burden and patients wouldn't have to... The way our plan is developed here in Michigan, patients wouldn't have to call multiple insurance companies if they're changing jobs. They wouldn't lose their provider network that's with one insurance company if they changed jobs to another place that has a different kind of insurance with a different network. And they, the way that we're looking at things is we wouldn't really wanna have anything required like prior auth or step therapy because we think that the people who should be making decisions about what care a patient gets is the patient and their provider.
0:17:22.9 CR: We shouldn't as the government funding their healthcare be the ones that decide what they get access to. So I think it's very likely to save a lot of money on administrative costs. And so that is really something I look forward to. But in addition to that, it is a more just system. It's more equitable, it's more fair. And I think Michiganders deserve it. We deserve to be able to live our lives without wondering whether or not we can afford to call an ambulance or go to the hospital, whether or not we can afford our meds, whether or not we have to try some med that we haven't tried before. Just because our coverage says we have to try it. To try the cheaper one. I have a constituent who might die if they try the wrong one. That, I mean, that's a really bad outcome, the worst outcome. So we need to stop it with those kinds of policies and move toward this universal coverage and universal payment structure, in my opinion.
0:18:21.2 DA: Thank you. Michelle, what's your perspective on the kind of the positive reasons to pursue this path?
0:18:25.0 DG: Yeah. So I have a master's degree in public health also from the University of Toledo. And so I really got interested in universal healthcare there, but it was my time on Toledo City Council where because of Cook County they used ARPA dollars to relieve medical debt for I think it was $12 million, oh, I'm sorry, a billion dollars that would be 12 million of ARPA dollars for Cook County residents. And I was like Hey, that's a great idea. I'm gonna bring it to Toledo. So we passed in November of 2022. We passed $800,000 of our ARPA dollars went to medical debt relief. We worked with... Used to be called RIP Medical Debt, now it's Undue Medical Debt. And two of our major hospitals came on board and the initiative not only just reached Toledo and Lucas County residents, but folks from across the region.
0:19:43.1 DG: And we have relieved medical debt for 113,000 people in the region. So that's how many people got letters. So that really sparked my interest again around universal healthcare single-payer Medicare for all. Because medical debt is the number one reason why people go into bankruptcy in this country. The number one reason, and it should not have to be that way, people should not be afraid to go to the doctor to pay their medical... Because they're gonna have a medical bill they can't pay. To choose whether or not they're gonna put food on the table or pay this medical bill that they just got in the mail that's a surprise. Or their anesthesiologist was not in network, so they have a bill for $6000, because they had to go under a procedure.
0:20:40.1 DG: So that's what really motivated me to continue this fight because we should... We are the richest country in the world. We're the only western country that does not have universal healthcare for our residents, and it shouldn't be that way. So that's why I continued to do this. Even though we get our guaranteed one hearing every general assembly, and that's really as far as our bill goes, but we need to keep the conversation going because it's really important for a lot of people in this country.
0:21:15.8 DA: Thanks. And Robin, your perspective?
0:21:18.1 RL: Yeah, thank you. So I got involved in Vermont's single-payer efforts, actually as a nonpartisan legislative staffer. I worked at the legislature when the second round of single-payer came up in Vermont in the mid 2000s. And so I've really... Most of my experience has been focused on the technical policy implementation details, which are fascinating if you're a policy wonk. But I think the energy in Vermont around single-payer really comes down to many of the issues that have already been raised, as well as really a core belief by Vermonters that healthcare is a human right, and that it shouldn't be subject to, as many folks have already said, that a lot of the challenges that we see in today's system. So I think that for Vermont, we've really focused on ensuring everybody has access and making sure that that access, is affordable. So those are two key components as well.
0:22:21.2 DA: Great. Well, so that sets the stage for my next question. You've all discussed some of the positive contributions that expanded health insurance coverage and a single-payer system could make, but it's obviously very complex. If it weren't, we'd already have the system in place. And so, while the vision of more equitable financial access to healthcare through universal insurance coverage is important, there's a wide array of stakeholders and legitimate concerns arise regarding how to pursue such major reform and how it would play out and be implemented. So I'd like you now to each pivot and comment on what you see as the most important challenges in terms of designing the system you're advocating and moving from the current system of public and private health insurance markets to a single-payer public system, and how the political and economic challenges might play out. And what are some of the biggest concerns that you hear from constituents and stakeholders? Michelle, could we start with you for this one?
0:23:14.0 DG: Yeah. So I think, again, one of the biggest issues, and I kind of addressed this before, is we have people who work for the insurance companies. So that would be a lot of job loss. Again, our bill does address that, but it may not address everybody's loss of a job. And that's something to factor in. I think a lot of people are afraid of change. I know when the a CA came out, president Obama was like you can... You don't have to change your provider. And then some people found out that's not necessarily true because some plans don't take different, some providers. So, I mean, it can be a little challenging that way, even though our plan lets you have that freedom and flexibility, people may not trust the government, right.
0:24:09.8 DG: To be able to give you that choice. So I think that those are some challenges. I think a lot of people hear stories coming out of other countries that have universal healthcare, like Canada and the United Kingdom and other European countries of stories where people have to wait months for procedures. So I think there's a lot of rhetoric around that. And I've talked to a few of my Canadian folks lately. I've met some Canadian legislators and said, not for necessary procedures, but maybe electives you have to wait a little bit longer. But typically it's not much different in those countries than it is here. But again, I think the reality is people are going bankrupt in this country, and I think we have to address that there is a larger issue with people not being able to pay their rent or pay their mortgage or being forced out of their home because they're in so much debt or they had to file for bankruptcy. So I think that's the challenges that we're facing here. And to really talk to people about the benefits of universal healthcare or single-payer I think is still really important because it's much better for the consumer because they won't have all that debt. So, yeah.
0:25:48.8 DA: And Robin, in your opening remarks, you touched on some of the challenges that Vermont faced in 2014 when the financing plan came together. Would you expand on that or highlight other challenges that you encountered in Vermont?
0:26:02.8 RL: Sure, Absolutely. Happy to. We have a lot of lessons learned that we are thrilled to share with other folks. So because we're one of the few states that have gone the next step after passing legislation in terms of actually drilling down into how do we operationalize this? How do we sign people up, how do we get the federal money into the trust fund where the road blocks. I think we've... A lot of what I'll have to say is really more about the practical then I think we had a lot of the same political questions that came up in passing the bill. And I would say sort of my top three are know your tax base and your business community so that you really understand who are the winners and losers under a new financing plan and transition, transition, transition.
0:26:52.6 RL: How are you gonna transition people from what they're doing today to the new system? We also had a ton of political upheaval during the Affordable Care Act implementation because we had a lot of people who even if they could "keep their own insurance" everybody was actually switching. And that's very scary to people. Next I would say the federal government and the federal waivers. There are federal waivers that were designed by actually our now Senator Bernie Sanders, to try and allow for single-payer at the state level. They need improvement. While they're theoretically helpful to get you there, there are still a lot of federal strings attached that make the implementation not as seamless as you want. So where we ended up landing with Medicare, for example, is having our state program wrap around Medicare as primary, because Medicare's not gonna hand over signups for Medicare to the state.
0:27:56.9 RL: And there's no legal provision that allows for that to happen by the federal government. But you achieved the same result where everyone has the same coverage. It's publicly financed. And for folks, I mean, most people, once they get on Medicare, they're very excited because finally you're gonna have insurance that you can keep. But the coverage is actually not that great. There's a lot of cost sharing for Medicare. So there was gonna be, we wanted to bring folks on Medicare up to the higher level of benefits that we would have under a single-payer system. And then the third area I would say is do not over promise on administrative costs. Because what we found is when we started thinking through, well, how is this actually gonna happen? Who are the people who are... The administrative costs turn into people?
0:28:46.2 RL: To your point with jobs and are your estimates granular enough that they're gonna take into consideration that if, for example, you have small doctors' practices and they have maybe two administrative people, one of whom does billing, are they gonna lay off that person or are they gonna keep them and find something else for them to do? So our administrative costs shrunk over time as we studied it more, which became a political problem. So I would encourage you to underestimate, spread it out over lots of years and then have it be a positive surprise if you can achieve more. So those were really the three areas. The political challenge was around the taxes, but the practical challenges in terms of actual implementation were those other areas. There were some situational things too, like the economy was slow, so the tax plan wouldn't deliver as much as we thought initially. And we'd just come out of the Affordable Care Act had a terrible exchange rollout and so everybody hated the government, so that didn't help either.
0:29:50.2 DA: So timing is often everything.
0:29:52.2 RL: Timing is everything. And transition, transition, transition.
0:29:55.9 DA: Carrie, what do you see as the political and economic challenges and views that you hear from colleagues and stakeholders?
0:30:02.0 CR: So we have not been able to have a hearing in our state legislature, but we have been able to do seven town halls from Marquette to Grand Rapids, Lansing, Detroit, Ann Arbor and also a couple of statewide town halls online. And we've heard some really great questions about plans that are ERISA regulated, the federal law that regulates benefits for employees. And so in Michigan we have a large proportion of our people's coverage that is provided by ERISA regulated plans and not state regulated. So that is something that we know will have to get some sort of exemption or workaround. We have spoken with Congressman Ro Khanna, who has a bill in the US Congress to create a state-based universal healthcare, a bill to allow state-based universal healthcare programs, which would then require the feds to approve such use of federal dollars and authorize a mechanism like you were saying, Robin, about having our state administer the Medicare dollars that come to our state.
0:31:04.6 CR: So we have heard folks wondering about that and we know that that will be a challenge. We also in Michigan, the way we have never introduced the funding bill, the corresponding funding bill, because one of the ways we wanna fund this is in part through an income tax and a payroll tax. And in Michigan, our state constitution only allows flat taxation. It does not allow graduated taxation the way that the federal government allows. And so in Michigan, we'd have to change our state constitution to change our taxing structure in order to find funding. And that doesn't scare me because we have seen in all the last like three or four elections, we've drastically expanded voting options for people in Michigan. We've protected abortion rights, we've even changed our term limits as I mentioned at the beginning. So it's totally possible to do that.
0:31:53.9 CR: And I think every year that we see the inequality grow in our state, the more people in Michigan wanna see a change. And I don't think it's gonna be that hard to light that spark to change that. So that doesn't daunt me. I have heard questions about snowbirds, which for those who haven't heard of this before in the winter in Michigan, a lot of folks go to warmer places across the country and they don't stay here. So does their Michigan MiCare coverage follow them to Arizona to Florida? That is a question that the MiCare board will need to figure out. And...
0:32:28.3 RL: I can help you out with that.
0:32:29.5 CR: Yes.
0:32:30.3 RL: I have an answer.
0:32:30.4 CR: Oh, great.
0:32:32.4 RL: For the snowbirds.
0:32:32.4 CR: And we've also talked about the job situation, right? Reducing multiple payers and the state administering MiCare will need to hire some of those folks for their expertise. But we also have a lot of other healthcare related jobs that we need folks to get retrained and work in those fields. We have a lot of care providing jobs and there will be a higher demand in care if everybody can access care. And so we are hoping that we'd be able to correspondingly increase training program funding for folks to be able to be retrained. We do have scholarships and things in Michigan for that already. And then the other thing that I've heard about and that our staff has talked about is when we turn the switch, we need to have money in the bucket already. So that we can pay for services. So, and we either roll out the turning the switch on after a year of people being taxed with nothing to show, or we bond for the money to fill up the bucket and then we pay it off over time as we start taxing folks. So this isn't an easy thing, but that doesn't scare us 'cause it's the right thing to do.
0:33:36.5 DA: So before we turn to Paula, maybe Robin, I'll just... You mentioned having some insight into the snowbird issue in Vermont.
0:33:41.0 RL: Yes, Yes. So what we were looking at for... 'cause of course Vermont, everybody goes to Florida for the winter if... Except for the people who like to ski. Yeah. So just like a smaller regional insurance company, you can actually contract with an insurance company to rent their network. And so that's what we were considering doing because we knew that we would have that issue. The other approach that we looked at was Medicaid, of course covers people out of state. So you can piggyback sometimes onto your Medicaid system depending on how that's designed. So those would be a couple ideas to look at. Great. Thank you.
0:34:19.0 DA: So Paula and now I'll turn to you as our Ford School faculty member on the panel. Is there research to help inform the discussion and the debates that we're discussing here? And what do we know about the economic implications of state-based single-payer systems and plans?
0:34:35.9 Paula Lantz: Thank you, John. And I wanna thank these incredibly busy, wonderful people for coming to the Ford School today to share with us your enthusiasm and your innovation and attempts at the state level to solve what is a uniquely American problem. And it does turn out there have been so many proposals over the years at the federal and state level for Medicare for all, Medicaid for all and different versions of it, that there actually has been quite a lot of research on it, mostly in the kind of economic forecasting, modeling flavor of research. The Congressional budget office has a model that they've run for a number of years. Some think tanks have models. There's some state-based models, economics professor at the University of Massachusetts at Amherst, Gerald Friedman has a model that he's been working on and refining for years and done analyses of a number of different states.
0:35:36.9 PL: So in fact, there's so many economic models of this that there is a systematic review article looking at the models that was published several years ago for the research nerds in the room. So this review article analyzed 22, what they considered high quality studies of either federal or state-based universal payer plans in the United States. And here's some high level findings from this modeling sort of work. The first one is that 19 or 86% of the 22 studies that were reviewed in this article predicted a net savings in healthcare expenditures. And the median net savings was three and a half percent across studies. Well, what does that mean? Basically the models look at somewhat different things, but what the models are looking at is if under status quo, how much would we expect in a year's time that both insurance companies and people and businesses would be spending on insurance premiums and then out-of-pocket costs for care, including prescription drugs, for sure. Most of the models did not include long term care when they were looking at it, but.
0:36:57.2 RL: I can imagine.
0:37:00.5 PL: But what would we expect in a state or the country in a year in terms of healthcare expenditures based on assumptions about utilization? And then if we had a single-payer system with all kinds of assumptions about that, what would we expect those expenditures to look like? And again, on average, the models predict that it would be lower. The range was three... Again, three studies predicted an increase. The biggest increase was 7% increase. But most of the models predicted a savings with the one that predicted the biggest savings being over 15%. That state would spend that much less.
0:37:45.0 PL: So there's three main reasons that most of the models predicted there would be a net savings in what a population would spend on healthcare. Number one, we've talked about it already, a reduction in administrative costs on the insurance side, both for payers and providers. And that, the mean across the studies was about 9% reduction in cost. And then also decreased drug and medical device prices and mostly from negotiating better costs, so not because there's gonna be people saying you can't have that, and having all these layers of approval, it's just negotiating with the manufacturers would lead to better costs passed on to patients.
0:38:37.5 PL: And also some of the studies predicted a small decrease in what is spent on healthcare because of decreased amounts of fraud and abuse within healthcare insurance. As all Ford School MPP students know and any kind of policy analyst knows, your predictive models are based on lots of assumptions, and so good modeling has you test those assumptions and you see if the modeling, the results you're forecasting are sensitive. It's called sensitivity analysis. The models are sensitive to the assumptions that go in, and of course they are. And I think a couple of areas where more work needs to be done, I'm really interested. We hinted about some of this before, but I would like to unpack this a little more. Assumptions about, well, where did the reductions in administrative costs come from? And they do come from people losing their jobs. They have to come from somewhere. Now, professor Friedman's model makes some assumptions about, well, the local economy might absorb some of those people.
0:39:53.0 PL: But I think that's very dependent upon where you are. I don't know, in a big state like Michigan, where actually health insurance and healthcare provision is a big part of our economy. And if some of those people, if the bureaucracy shrinks a little bit and some of those people need different jobs, where are they gonna go? Are they gonna move to other places for them? What happens to a local community that loses some of those jobs? So I think the modeling is just sort of silent on that 'cause it's complicated, right? So I think we need to think about that a little bit more. And I'm not as sanguine as Professor Friedman and some other people about how, well, yeah, some people are gonna lose their jobs, but they'll find something else. I think there's gonna be impact on people and on communities where those jobs are lost.
0:40:42.3 PL: And then just another quick issue I'll raise is that the cost savings are also somewhat dependent on perhaps caps on what some providers make. And you know, that's not gonna go over real well with some people. So you might think, well, that's a political problem for sure. But I also wanna think about how in the US right now, we have a lot of workforce issues in the healthcare workforce. And one cause of many of these issues is the incredible, and I say that sitting at a university that does a lot of medical and clinical care education, the cost of education is huge and lots of people going into practice medicine for sure. But other fields, pharmacy nursing, nurse anesthetists, whatever, name your favorite kind of healthcare provider, physical therapists, many people are going into medical debts or educational debt to pay for their training.
0:41:43.0 PL: And if they're not gonna make the kinds of money that people had in the past, or it's gonna take them much longer, I think we're gonna see some workforce issues. We already have really serious workforce issues in primary care where people don't want to go into primary care because they can't pay back their medical debt. So those are a couple of things that I think the... Why the literature, again, from the modeling is pretty positive about the potential for saving money with universal payer systems, I think there are some things we need to unpack a little bit more. And then how are we doing on time? Should we talk politics just a little bit about this? And there's lots to talk about, but I don't know how much stock you all put into the public opinion polling, but I think it can give us some signals about, I think mostly how well people understand the issue, maybe more than what their opinions are about it.
0:42:43.9 PL: But it turns out, if you look at over time, there's been a lot of public opinion appalling about, you know, do you think our healthcare, health insurance system is messed up? And most people agree that it is. But what should we do about it? And these polls ask different questions about, well, whose responsibility is it? Is it the government's? Is it the private insurance company's responsibility to fix a broken system or is it a mix of the two? And that kind of waxes and wanes over time. What we do know from, let's look, four years ago at a Pew Research Center poll, 37% of the adult respondents in the US said that it's not at all the government's responsibility to solve the problem of health insurance in this country. 36% said it is the government's problem and they want a national government single-payer sort of system. And then 26% of people said it's a mix of public and private. Do you think that varies bipartisan identification?
0:43:51.1 CR: What about Medicare coverage status? What percent of the people who don't think government should be involved are on Medicare?
0:44:00.4 PL: Yeah. Again, I think... What this tells you, the issues are so complicated, what does the general public understand? But a more recent poll from 2022, a Gallup poll, 57% said it is the government... So it's gone up from 2020 to 2022. It is the government's responsibility to ensure health care coverage, health insurance for all and 53% favor a health system based on private insurance. 43% a government run one, but again, huge difference, even a bigger polarization between people who identify as Democrats or Democratic leaning versus Republicans, so. I'll stop there.
0:44:40.0 DA: Well, thank you for framing some of that extensive research and I guess I turn to the other members of our panel for your thoughts on some of the topics that Paula covered.
0:44:52.1 RL: Sure. I'll jump in. Yeah, so I think the job loss issue is a real one. We did a study as part of our... I spent basically six years working on this project so it was a long time. We did a lot of work. We did a study on job loss and retraining and what kind of retraining should we consider? And so we came up with a number of ideas for how folks who would be losing jobs from the administrative costs could be retrained into other fields. So that was gonna be our approach. Also we assumed it would be, you know, it's not gonna all necessarily happen immediately on the medical side, at least. On the insurance side, I think it could be more abrupt, but on the medical side, I think it would take some time for that to work through. The other thing that we looked at related to the administrative costs was potentially partnering with, we have one locally based insurance company in Vermont. It's Blue Cross Blue Shield of Vermont. It's a statutory entity, so it never privatized like many of the Blues around the country. So we were looking at potentially partnering with them, so maintaining their workforce and their infrastructure in order to kind of address some of those issues. So that's one of the things that we looked at related to that issue.
0:46:23.4 DA: Other thoughts, Carrie or Michelle?
0:46:26.3 CR: I think that today in 2024, there is a different opinion of our healthcare system than there was before the pandemic.
0:46:32.2 RL: Yes.
0:46:32.6 CR: And I think the general public has a different view of our healthcare coverage being connected to our job. Because there are massive job loss situations that could result in people losing their healthcare. And in this case, it was losing your healthcare coverage when you had a healthcare issue happening. And so that is the most unfortunate kind of combination, right? So I think the general public is turning a tide here and starting to ask questions about why is this this way? A few minutes ago you said if this was easy we would've already done it, but I don't think that's true. I think it's 'cause our country made up our healthcare system in little patchworks here and there over the years and just kept making the decision that made sense at the time that that decision had to be made.
0:47:21.7 CR: But a lot of other countries started their healthcare systems after we did, and they started on the right track, right? That's why they're there. We have to fix... We have to not just go in the right direction, we have to turn ourselves around from going in the wrong direction, stop that, turn all the way back around to go in the right direction. I mean, it's harder for us to completely redo a very difficult and completely discombobulating system. So I do think that the general public tide is turning and you know, like I said before, I think this will take a while here in Michigan. And if the public opinion is gonna be ready for this in six years, eight years, but we will have, it'll take eight years for it to work. Why don't we start now and be working on this, getting out some kinks, figuring out the implementation, figuring out the job retraining, and then when the public tide catches up to us, we'll be ready for this to happen. So that's why even though I'm not getting hearings, I still think it's worth it to do this work now and have all the naysayers. I love talking to naysayers. So that we can figure out how to make this work when everybody else is ready for it.
0:48:32.2 RL: It's like that proverbial when the policy window opens and you don't really ever know when the politics will allow it, you better with something this complicated, be ready to kind of try to push it through.
0:48:42.4 CR: Yes. And people who are scared, they will go to a person that has a plan. So making sure that we have plans for when the rest of us are ready for them is what we really need to be doing.
0:48:54.3 DA: Anything you'd add, Michelle?
0:48:55.6 DG: Yeah, no, I think Carrie and Robin have had really good insights on that. And you know, I think it's really important, you know, ours has been introduced for a few decades now. To keep that conversation going because I agree with Carrie that the attitudes are shifting and the years on that polling really struck me because it was during pandemic and after pandemic. So I think that the public opinion is shifting and saying, wait a minute, something's not quite right. Why are we letting people go bankrupt over a medical bill? Maybe over from maybe a broken arm to cancer. People are going bankrupt and just can't pay their bills. So I think that our fight on the state level is so important just to make sure that we keep that conversation going and bringing that conversation to light because it is... I mean, it's a matter of life and death for a lot of people. And that's what really keeps me wanting to introduce this every general assembly and wanting to fight for universal healthcare because it is literally a life and death issue for a lot of people.
0:50:21.4 DA: Well, I want to ask you a follow-up question about some of the economic models you discussed. In the current system, one of the main ways that the government subsidizes employer-sponsored health insurance is by enabling people to use pretax dollars to purchase their insurance. And that ends up being a big expense for the government. Often a hidden one, but one that Americans seem to value. How do the models account for that feature of the current system and how it might change with a single-payer system?
0:50:52.2 PL: Yeah, you're asking me to recall the incredible weeds of these models, but the CBO's model does that, right? So at a national level, takes that into account. The state based models that I'm thinking of don't.
0:51:05.3 DA: Don't, 'cause it would... It's a federal policy.
0:51:08.8 PL: Yeah. Yeah.
0:51:09.4 DA: And that leads to my next question for the panel.
0:51:12.0 CR: We did actually because that became a big political issue when we were developing the tax plan is, but you're gonna lose all this pre-tax funding. So that was something that we had to work into our financial modeling. Yeah.
0:51:22.8 DA: Which leads to my next question for all the panelists. How do state focused proposals sort of interact with federal policy to facilitate the goals that you have? I think each of you have touched in different ways with sort of communication or federal regulations and laws that might influence state's ability to do this. And sort of, could you expand on that and sort of how do you coordinate your state approaches with the federal context?
0:51:49.0 CR: Two things I would say. The bill I mentioned from Congressman Khanna would allow states to do state level single-payer. I personally think the best way to do this is at the 330 million risk pool size of the entire country. That's a way better risk pool than 10 million here in Michigan. If you think 10 million's big, collecting 330 million is much better. So I do think this should happen at the federal level, but it requires legislation. And I think we've seen in a divided Congress this term that is very far off the table. We'll have to see what happens in future congresses, but I think that the way that many things have happened on a national basis have started in the states.
0:52:30.2 CR: And if we get enough states, especially big states like Michigan, to really give this a shot and keep the conversation going, the feds will eventually be looking over their shoulders like, maybe we should do this. Learn from what we are doing in the states and get it together. And I do think that there's a chance, you know, in the next six, eight years that the public tide will turn and this will be a much bigger topic at presidential debates, congressional elections and things. So I do think that we're heading in that direction. But I do think the pressure from the states is eventually gonna help the feds.
0:53:07.8 DG: Yeah. Oh, I'm just kind of thinking about our shift around cannabis. I think it's now 26 states. We just legalized it last year and our recreational has started. States are driving that conversation with cannabis legalization. And now the feds are looking at dropping cannabis from a Schedule one, right? Okay. I have it right. Okay. Schedule 1 to a Schedule 3. So we're driving that conversation, and I think Carrie is right, is that, you know, states continuing to drive the conversation around universal healthcare, I think will really pressure the federal government into acting because it is something that we can continue to drive that conversation. So I think that's correct.
0:54:08.0 DA: Okay.
0:54:09.4 CR: Yeah. And I would say, so this was a major theme in our research and work around implementation because we were looking at the status quo of what waivers could you get for Medicaid? What waivers can you get for Medicare? And how would that intersect with what we wanted to do? And you can get there, but the end result is not going to be pure. So one of the things that we found is that we started to lose some of the left because it wasn't as pure single-payer as they had been hoping for. So I mentioned one example, wrapping around Medicare. So instead of, you know, we looked at several different options for Medicare. We looked at being the regional... Bidding to be the regional administrator for Medicare. That just wasn't really feasible. I mean, Vermont's 650,000 people, so we're like a big city most other places, but spread out over an entire state. So we're rural and small.
0:55:11.6 CR: So I think, you know, if you can't get the change at the federal level, I think states can still do it. You just have to be willing and able to politically compromise some to get a better system that may not be the ideal system. So don't let the enemy... What's that saying? Don't let the perfect be the enemy of the good enough.
0:55:33.8 DG: Yeah.
0:55:34.5 CR: So that's sort of where we ended up with our planning.
0:55:36.7 DA: Great. Well, thanks. Now we'll turn to questions from our audience, both those of you here in person as well as those online. As a reminder, if you're here in the room with us, please use the QR code to submit your question to Ellie Bi, and she will walk us through the Q&A session here. So we'll turn to Ellie for the first question.
0:55:57.5 Ellie Bi: Some advocates of universal insurance coverage have proposed Medicaid for all, Medicare for All, or Medicare Advantage for All as the way to achieve universal coverage. What strength and limitations of such an approach do you foresee for individual states and nation?
0:56:15.9 DA: Oh, thank you, Ellie. Just to repeat the, you know, the proposals for Medicare for All, or even Medicare Advantage for All, which is the sort of the privately administered form of Medicare that now covers a little over half of all Medicare beneficiaries. So how would that play out in your perspective? Is that an option on the table for states?
0:56:36.0 S?: I am specifically trying to avoid Medicare Advantage for All, because I want this to be publicly administered, which will be closer to Medicaid for All, really, than even current Medicare for All, because Medicare itself doesn't cover everything I would like to see covered in a public system. And so I would say, comparing and contrasting these ideas, if I had to pick between those three only, I would be looking at Medicaid for All.
0:57:06.2 RL: With better reimbursement rates?
0:57:08.7 S?: Yes, in our bill, we actually list that reimbursement rates are 125% of Medicare, and that devices are using federally VA negotiated rates. So those are some things that we wrote into our bill, but that's kind of where I'd compare and contrast that question.
0:57:29.2 DA: Any thoughts on that question?
0:57:29.3 CR: Yeah, I think I agree, because the problem with both Medicare and Medicare Advantage is that for many folks who are used to employer-sponsored insurance, you're gonna decrease their coverage. And so, and I don't think that's the goal. I think the goal is to ensure that everybody has the coverage that they need to seek the care that they need.
0:57:50.1 DA: Next question, El?
0:57:53.4 EB: The last time there was health care expansion in the United States, it was after two Democratic landslides in 2006 and 2008. Is the only way for a single-payer to come to fruition by having another electoral anomaly? Is it by ending the filibuster, or is there any other way?
0:58:17.9 CR: So to me, those all sound really like a focus at the federal level. And so at the state level, it's a little bit different, because each state's politics may or may not be mirroring what's happening at the federal stage. So for example, with our efforts, our efforts were '95, 2005, and 2011, which I don't think neatly kind of hits any, the same pattern as the feds. I do think for us, having a governor run for office on single-payer, the political aspect of that did really heighten the issue, got a lot of excitement going. And so that was really helpful. I don't really feel like I can comment on sort of what's going to work at the federal level. I think anybody else's guess is as good as mine.
0:59:10.9 S?: Yeah, I'd rather not comment on the federal level.
0:59:14.1 S?: Yeah. Same.
0:59:18.9 EB: I'm a resident of Minnesota and an advocate of the proposed single-payer Minnesota Health Plan. I found that people's objection to single-payer included distrust of government as administrator. How do you in other states propose to earn that trust to get the public support?
0:59:46.5 CR: I mean, I would say something to think about here is that what we're proposing in Michigan is a government-funded, privately-delivered health care system. So we're not having a takeover of the government of all the providers, right? This is not the VA for all. This is Medicare as a payer for all. So for all of the taxpayers in Michigan, right now we are okay with being taxed and having the government decide about our road funding. I know we can do better. But that is an example, right? It's publicly funded. And the same with public schools, right? We're trusting the government to finance something. In Michigan, of course, that's for the public schools to be administered publicly too. But I think there's a couple of different ways to look at that trust question. We're not asking the general public to trust government-employed providers. We're asking them to trust us to help make sure that the risk is spread among the 10 million Michiganders or however many people in whatever state and to administer the funds in a more equitable way.
1:00:58.0 DG: Yeah, no, I think that's a good point. So our bill is very similar. We're not telling providers how to run their medical practice. But we have a single public fund to make sure that everybody's covered. And to your point with public schools, we also fund public libraries. And we fund our police and fire with public dollars. So I think that's important with the trust issue is that we, there's a lot, our tax dollars go to a lot of public services. And it would just be another public service. But the providers are able to make decisions between patients and providers.
1:01:54.1 PL: Yeah, I don't know. We just lived through a pandemic that I thought maybe naively sort of at the beginning of the pandemic being a public health person. I've worked in state government and county government before too, but I thought, "Oh, this is maybe a time when the general population is gonna understand public health more and the way it's a partnership." In this case, it's definitely a partnership with every other aspect of the economy, but certainly the healthcare delivery system. And boy, right? I mean, the measures of trust in governments weigh down. And I think the understanding of what is it, a shared goals that we all have as a society and what services can government provide and pretty political, politicized rejections of a lot of that. I am sitting here now worried that we were not prepared for the last pandemic and we are less prepared now for major public health problems. So I mean, you're sitting in government, closer to government than me, but I'm worried.
1:03:17.2 CR: But I think for me, the difference is with the pandemic response, it was a lot of government employees who were government funded. What we're talking about is a privately delivered service that everybody goes to their provider that they know in the private sector for the most part. Some people definitely go to the public sector, but I think that Americans, Michiganders wanna stop having to do the mental calculus of how they're gonna pay for the thing they need. And.
1:03:44.8 PL: But a lot of the messaging is gonna be coming from...
1:03:47.8 CR: Opposition.
1:03:48.6 PL: The state. No, we're saying, "Hey, we're... " I mean, this is huge reform, right?
1:03:53.8 CR: Yeah.
1:03:54.8 PL: Who's gonna be explaining it to people?
1:03:56.7 CR: Well, and but like you're talking about with the policy window, once the general public is like, had enough of the way it is, I think we can capture on that and talk to them and what they're complaining about, talk to 'em in the language of what they're complaining about. And I don't think it has to just be state people doing it. I think Magic Johnson might wanna get involved. He's not a state government employee, for example.
1:04:21.5 RL: I think trust is interesting to think about because for us, we had a bad implementation of the exchange. Prior to that, there was a lot of trust in government in Vermont because we had a very successful kids program. I mentioned Dr. Dinosaur with tons of kids who got their insurance through the state insurance. And so that really built trust. And, but then the exchange rollout eroded the trust. So I do think, but then in the pandemic, our trust actually went up 'cause we had a fabulous pandemic rollout. And we currently have, we had at the time and still do have a Republican governor and he's basically considered like undefeatable because of how well our pandemic rollout went. So I do think it kind of ebbs and flows based on how things are going. And so maybe that's an advantage, quite frankly, at the state level, because when you get to a smaller group to communicate to, you can build trust maybe more easily than at the national level. I don't know, just some thoughts that came to me based on your comments.
1:05:33.6 DA: So another question from the audience.
1:05:38.1 EB: What lessons can the US learn from all the other countries that have implemented single-payer systems?
1:05:47.2 CR: Shall I jump in?
1:05:48.4 S?: Yeah.
1:05:49.1 CR: We looked at a lot of other countries when we were designing our system. We looked at for example, at cost sharing. So in the United States, I think because of our proximity to Canada, we tend to think when we think single-payer, we think no cost sharing. That's not true in most European countries. So there are sometimes good reasons to have some cost sharing, as long as it's income sensitive, because we do know if you're low income and you have even a small coinsurance that impedes access. So ensuring that you're being income sensitive in any of that. So we looked at other countries to kind of get a sense of the range and then compared it to what we had in the state to try and come up with something reasonable. And then we looked at a number of different ways that it's administered. So in England, they do own the doctors.
1:06:39.1 CR: Like The National Health Trust employs the doctors. That was a step too far for us. Canada, it's more like a fund system, but and it's province by province, so there's a lot of variation. But they have some provinces that have, like don't cover mental health, for example, which was sort of a deal breaker for us. But there are some countries in Europe that use a private administration as well as with the public financing, but ensures that there's still one administrative system.
1:07:09.8 CR: So that's sort of the direction we were leaning, thinking that that could also allow us to avoid some of the job loss, quite frankly, in order to implement. So I think if you've seen one single-payer system, you've seen one single-payer system. So there's certainly a lot of lessons learned, but you then need to bring it back and tailor it to your local environment and really understand whether that would work for you or not.
1:07:36.6 DA: Any other thoughts on other countries, how they approach this?
1:07:40.0 DG: I mean, they're doing it at the national level, and we're talking about the state level here today. So there's, I would say, basically what you covered with the things that we can pull into the state level, especially once you have a large enough population as a state that kind of compares to some countries that have single-payer systems or more universal coverage systems, but not necessarily publicly administered single-payer. So I do, I like those distinctions.
1:08:08.6 RL: Yep.
1:08:10.4 DA: Another question, Ellie?
1:08:15.4 EB: Question to all speakers. So at the moment, a large amount of employees have employer-provided health insurance. With this in mind, what are ways large employers in the states could help fund health care? Could a single-payer plan be cheaper for them?
1:08:36.3 CR: Yes, yes. So I think the question, if I think I got it right, please correct me, is that given the large extent of employer provision of health insurance, how do you ensure that employers are still participating in a way? And I think that's why a lot of states look to the payroll tax, because it's a way to recapture some of those employer benefits that are currently being provided. And certainly in Vermont, we did have winners and losers. We have lots of small companies, as I said, that weren't providing any coverage. And so they were the losers. But the state, I think state is like almost 20% of state budget goes to health care. So the state employee plan, for example, would be a big winner.
1:09:29.0 RL: I think something interesting here is about the large employers. And so the difference between Vermont doing your plan and what we're talking about today in 2024 is that you were really trying to roll this out before the Affordable Care Act increased coverage and increased mandates on businesses and employers to cover their employees. And I think in my mind, the way we would build it out in Michigan, once we effectively change our state constitution, so assume that already happened. And then after that, we would need to figure out an appropriate tax for different sized employers. Also assuming the ERISA problem isn't here. So a couple assumptions, just like you do in policy. So state constitution change, ERISA's figured out. And then we'd figure out the appropriate level of tax for the different level sizes of employers. But for many employers right now, health care is one of their biggest expenses. And I've been talking to a lot of large labor unions who have members that are members of the union and the union is what provides their health care coverage. And some of them are multi-state.
1:10:32.1 RL: Union coverage. And so that is where it gets complicated too, because they're looking at this as a benefit for their members, but also it is something that is negotiated with the employers in some cases. And so it is, when talking to some union members, like I talked to Shawn Fain not too long ago, and he said, in UAW, we'd love to chuck the health care off our table. We'd love to just negotiate on wages and working conditions. Like, great, give us more power for those two, get this other thing off our plate.
1:11:01.8 S?: Great.
1:11:03.1 RL: So there's a couple other things to consider too. Do you have anything to add?
1:11:07.9 DA: Anything you'd like to add?
1:11:08.8 CR: I think, yeah, absolutely. A lot of labor unions, when they go back to the negotiating table, it's a lot about health care costs and what they cover. So certainly I remember that when my mother's union stuff was back on the bargaining table. Sometimes they would have to change insurance because of what happened on the negotiating table. So yeah, no, I think that's a really important point, is that employer costs, health care is really high, labor unions, those negotiations, I think that would really just change the conversation around many things with negotiations of, with your employer or with your labor union. So I think that's really important.
1:12:01.0 CR: Many of the employers that we talk to, they're basically like, "Sure, I'd love to get rid of health insurance. I didn't build my business to provide health insurance. I built my business to do this business. And in order for me to feel good about my benefit package, I have to do this other thing. But if that was off my plate, great." But I mean, it did come down to whether or not the peril tax is more or less than they are currently paying, of course. But just sort of theoretically, we found a lot of openness from employers.
1:12:31.8 DA: Ellie, I think we have time for one more question and then we'll wrap up.
1:12:38.0 EB: Can you expand on how your state's plan might go about, or in Vermont's case, have done in determining prices for health care services?
1:12:48.5 CR: Do you understand the middle part?
1:12:57.2 EB: So, should I just repeat the question?
1:12:57.4 CR: Yes.
1:13:00.0 EB: Cool. So can you expand on how your state's plan might go about, or in Vermont's case, have done in determining prices for health care services?
1:13:09.9 DA: Yeah, what has your state done in determining prices? Or how would it determine prices for health care services?
1:13:15.8 CR: Yeah, so what we did, so we thought about the prices in terms of reimbursement to health care providers. And as folks may or may not know, Medicaid typically pays less than Medicare, which pays less than commercial. And so what we kind of did is look at, well, what if you threw that all in a bucket and you kind of evened it out, what would you be paying? So that's what we were looking to do, is keep providers whole by bringing down sort of the commercial side, up what would be Medicare and would be Medicaid. So that's really sort of how we approached it. I'm sure there's lots of other ways you could look at it, but.
1:14:00.8 Speaker 7: Are you talking about MiCare?
1:14:04.4 CR: Yes, yep.
1:14:04.7 DA: And anything else from Ohio or Michigan?
1:14:09.7 DG: I can't remember. There is an analysis, if you go to our legislature's website, it's a 24 page analysis. So I'm sure that that's there. Again, being newer to the bill, not the one introducing it 11 times, I don't know the ins and outs as much as Rep Skindell, but I'm sure I will learn those very soon. But yeah, if you go to the website, there is actually an analysis, so you don't have to read the entire bill that our Legislative Services Commission did. And it kind of gives you more of the details with that. So it's legislature.ohio.gov. And it's House Bill 174, if you wanna look it up.
1:14:53.5 DG: In Michigan, in our MiCare bill, we have put in there that we would like our MiCare payment to be at 125% of the Medicare rate. And that's because Medicare will have negotiated a rate at the federal level, and in Michigan we'll just tie it to that, so that we're not the ones necessarily having to spend the administrative time doing that negotiation. We also tie devices to VA negotiated rates as well. So that's what we're looking at. And then as far as hospital payment, we are looking at, it's not in the bill, but one thing we wanna think about for reintroduction is global budgeting with hospitals, especially since Michigan has so many rural hospitals that really have a base fixed cost that they need to actually have all the machines on with the beats and the boops. And then after that, their volume can determine how much more they can make. But they need a minimum amount to stay literally plugged in and on. So how do we figure out how to keep access in every corner of Michigan's two pleasant peninsulas?
1:15:52.8 DA: Great. Well, so we're nearing the end of our session today. I wanna give each of our panelists a chance to share a take home message or a crystal ball prediction of kind of where we go forward with the health insurance reform at the state level. Robin?
1:16:07.5 RL: I think the idea of global budgeting is really interesting right now. It's a hot topic in many states and also at Medicare and the Medicare's proposing hospital global budgets as a pilot project for some states. And I think thinking about that as a payment methodology and combined with public financing could be really interesting. So I think that that aspect of it will get a lot more attention in the coming future.
1:16:40.4 RL: I think that, I think more people are going to start getting on board with some type of universal coverage. The cost of healthcare has been a big message in this election season. I think people are really feeling the pinch with healthcare, especially necessary medicines like insulin. Again, where life and death situation people need to stay alive and they're paying hundreds of dollars a month for something that's gonna, that keeps them alive. And I think that we're gonna see a lot more people really demand some action from their government around some form of public coverage.
1:17:32.0 RL: I already said, I think the public opinion is gonna shift in six to eight years and we just need to be ready for it and that we're not intimidated by changing our state's constitution and getting federal approvals. But one thing I will say that's tangible is that I've been in talks with Congresswoman Jayapal from Washington, who is the sponsor of the federal Medicare for All. And we're trying to coordinate the states with Medicare for All bills and the federal Medicare for All bill reintroduction next term in the spring and really try to keep the pressure on because this is a conversation that needs to keep in the limelight in order for us to actually turn that public opinion. It's not gonna turn itself. So we need to be the cogs to just keep doing the work to make that happen.
1:18:17.4 DA: Paula.
1:18:17.6 PL: So because I've been doing a lot of work lately on direct democracy powers in different states. So in what states do citizens have the power to actually bring something to the ballot box to change the constitution or to introduce a new law? And it turns out Michigan's one of them and Ohio's one of them, but only 23 states have, citizens have the power to bring a constitutional change to the ballot box. And there's research showing that legislatures don't like that so much. And so there's been pushback as you saw in Ohio of trying to increase the, is it 50% plus one vote where something at the ballot box has pass or tried to change it to 60.
1:19:01.6 RL: 60. Yeah.
1:19:03.4 PL: 60%. That didn't pass?
1:19:06.8 RL: No.
1:19:07.1 PL: But anyway, we're seeing that sort of this pushback against citizen initiated referenda and constitutional amendment. Not all states have that power, first of all, and then there's been pushback against it. So, I love hanging around with this woman. She's so positive about it. I feel like, I always feel big Debbie Downer next to her, but I learned and I've been doing health care and health policy research for a while. I didn't realize till I started hanging around with Carrie a little more, how many states have been thinking about this and for so long, it's an issue I just thought was at the federal level. So I just wanna thank you all for coming here today and helping not only to educate me about this a little more, but I think kind of, the general public that states are being innovative. States are saying, let's not wait for the federal government to do the, there are things that states can do. So thank you all for your work and for being here today.
1:20:01.2 RL: Yeah, thank you. Thank you.
[applause]
1:20:08.0 DA: So I'd like to add my thanks to those of you joining in person and online for this policy talk event at the Ford School and encourage those of you who are here with us in person to join us for more informal discussion at the reception. I wanna thank again, Martha Darling and Dr. Gil Omenn for their support of this event. And please join me in thanking our panelists, Carrie Rheingans, Michelle Grim, Robin Lunge and Paula Lantz for a very inspiring discussion.
[applause]
1:20:36.6 S?: Thank you, John.
1:20:36.7 S?: Thank you, John.
