Policies and Politics of the US Health Care System

Good afternoon, everyone.

I’m delighted that you’re here.

I’m Liz Cohen.

I’m Dean of the Radcliffe
Institute for Advanced Study,

and I am very delighted
that you could join us

for today’s conference on
the Politics and the Policies

of Health Care in
the United States.

As Harvard’s Institute
for Advanced Study,

Radcliffe is charged
with a dual mission,

to foster and to share
transformative ideas

across academic disciplines.

We do this by convening
and supporting

scholars, scientists,
artists, and professionals

from around the world
who work together

on the forefront
of their fields.

And we share their work with
a broad and interested public

through a full
calendar of events,

including lectures,
performances, conferences,

and exhibitions.

We at Radcliffe are
especially proud of events

like this one, which cut
across traditional disciplines

to wrestle with complex
issues of public importance.

To understand the dynamics and
challenges of the US health

the system, we have to
understand the interplay

of history, politics, economics,
science, and medicine.

Today’s distinguished
panelists bring a wide range

of expertise in these areas,
and I am grateful to them

for taking the time to be
with us this afternoon.

Our discussion feels
especially important in light

of the health impact
of natural disasters

like hurricane
Harvey and hurricane

Irma, which left hundreds
if not thousands in need

of urgent medical attention
and could lead to longer

term public health challenges.

Today’s conference also
marks the beginning

of Radcliffe’s two
year initiative

on citizenship, which is
motivated in part by our desire

to contextualize the upcoming
100th anniversary of American

Women’s Suffrage in 2020.

This discussion
today is the first

of many, we are planning
over the next two years

to delve into different aspects
of what citizenship entails,

how it is defined,
and who can claim it?

As today’s title suggests,
here in the United States,

citizenship can be
especially complicated,

with benefits and obligations
that vary from one state

to another.

It really does depend
on what state you’re in.

Since the nation’s
independence Americans

have struggled to find and
have often fiercely disagreed

over the appropriate balance
between federal, state,

and local government.

This tension has broad
implications for policy

and it has proved
an important factor

in the intense current
the debate over health care.

For much of the 19th
century, the United States

had a relatively weak
central government

and a more powerful state
and local government.

Geography often
determine people’s access

to public resources and the
the extent to which government

protected individual rights.

In other words, the
benefits of citizenship

very much depended on wherein
the United States you lived.

Beginning with the
progressive movement

at the turn of the 20th
century, the federal government

started to take on a
a larger role in addressing

economic and social problems.

Congress passed the Pure
Food and Drug Act in 1906,

and other new nationwide
standards quickly followed.

The New Deal in the
The 1930s, the emergence

of the Cold War security
state after World War II,

and the Great Society
programs of the 1960s,

which for today’s
purposes, notably

created Medicare and Medicaid.

Each marked further expansion of
the federal government’s role.

Although states
maintained responsibility

for implementation of
many federal programs,

uniformity across
state lines increased.

Then, in the early 1970s,
President Richard Nixon’s

“new federalism” began to
reverse the trend by increasing

state and local control.

New federalism’s block grants
gave states broad discretion

over social spending.

This is particularly relevant
to our discussion today.

For example, earlier this
year several top Republican

lawmakers, including speaker
of the House Paul Ryan

articulated a vision
for converting Medicaid

to a federal block
grant program.

The shift beginning in the
The 1970s towards dismantling

federal authority in
favor of state discretion

did not belong to any
one political party

in the years since Nixon.

Jimmy Carter did his part.

Ronald Reagan ferociously
attacked federally funded

programs.

And Bill Clinton’s 1996 welfare
the reform replaced the New Deal

era Aid to Families
with Dependent Children

Program with a Temporary
Assistance to Needy Families,

or the TANF block grants.

The result, for
better or worse, has

been declining federal
control over the social safety

net for almost a half-century.

And in turn, dramatic variation
in benefits and eligibility

requirements from
state to state.

These stark differences can be
seen in how each state chooses

to allocate TANF funds.

South Dakota spends
61% on cash assistance.

Texas spends 7%.

And each state sets
its own lifetime limit

on TANF benefits.

Here in Massachusetts,
the cap is five years.

In Arizona, it is 12 months.

The Affordable
Care Act, which we

refer to as the
ACA, or Obamacare,

is very much a part
of this history.

When the ACA passed in
2010, it dramatically

expanded the federal
government’s role

in regulating both
the health insurance

industry and individual
choices about health coverage.

At the same time,
the ACA’s design,

and much of the debate
before and after its launch,

has clearly reflected
deep disagreements

over the extent of state
versus federal authority, which

has been a part of
American politics

since the nation’s
establishment.

With all of this
history in mind,

and I am a historian
so I can’t think

about the problem
any other way, I

look forward to learning
more with you today

about the debates that are
still swirling around Obamacare

and the future prospects for
health care in the United

States.

So to get our afternoon started,
I would now like to hand things

over to Professor Dan Carpenter.

Dan is the Faculty Director
of the Social Sciences Program

at the Radcliffe Institute,
the Allie S. Freed Professor

of Government in the faculty
of Arts and Sciences,

and the co-organizer with
Professor Janet RichEdwards

of today’s symposium.

Please join me in welcoming
Dan to the podium.

– Thank you Liz, and
Welcome everybody

to the Radcliffe Institute.

It seems just a short
while ago, but so long ago

that the United States entered
a heated, what at the time

seemed interminable, battle over
what is now known as Obamacare?

Obamacare, the ACA,
seems like a settled

fact in some discussions,
but it is not.

And in case you forgot,
here are a few things

that happened in 2009, 2010.

There was a bill in the
House of Representatives

that passed that
chamber with what

was called a public option,
namely the ability of consumers

to choose a Medicare-like
plan as part of their health

insurance plan menu.

There was the refusal by Senator
Joseph Lieberman of Connecticut

to support that public option.

Which, given his pivotal
status in the Senate

at the time as the Democratic
Party’s 60th coalition voter,

killed that plan.

There was the passage of a
different Affordable Care Act

by the US Senate.

There was, as residents of
this state may remember,

the unexpected electoral
the victory of Senator Scott

Brown in January 2010.

Which seemed, at
the time, according

to many prognosticators,
to kill the whole effort.

There were the efforts
after that by the speaker

Nancy Pelosi to resurrect
the bill that had previously

passed the Senate in the
House of Representatives,

successfully through the
house, and on to President

Obama for his signature.

There was the botched
the rollout of the ACA website

by the US federal government.

There were the massive
Republican gains

in the midterms of 2010.

There was the first
Supreme Court case

on the ACA, NFIB
versus Sebelius,

which upheld the
law by a thread,

and which gave states
the right to opt-out

of Medicare expansion.

And then there was a
second, not only the only,

but a second Supreme Court
case on the ACA, King

versus Burwell, which,
to put it simply,

upheld the law’s subsidies.

Anyone of these hurdles,
and there were many others,

could have tripped up the.

ACA.

And now we too
easily regard the ACA

as part of a status quo, albeit
admittedly an unsettled one.

Today, the architecture
of the Affordable Care Act

has done some amazing things, as
we’ll hear from our panelists.

The percentage of
American adults

who lack health insurance
has fallen to historic lows.

Today’s symposium will show the
politics of health insurance

have everything to do with
the ACA’s achievements

and limitations.

Health insurance systems
depend as much, maybe m

upon political
institutions as they

do upon market characteristics
and system design.

The ACA is today under
attack on two fronts.

The first is probably
better known.

The day after the
November 2016 election,

I predicted to my students
in a bureaucratic politics

class at Harvard, that
the ACA would be repealed.

The Republicans
simply had to do it,

I reasoned, as it had been
their mantra for eight years.

And for now, I am wrong
in that prediction,

and I hope I remain so.

Yet Repeal and Replace, with
its ever-larger estimates

of those who will
lose health insurance,

may still pass at some level.

And of course, the
federal subsidies

undergirding
regional marketplaces

are in jeopardy as well from
the decisions of the Trump

administration.

Today’s first
panel will describe

some of the politics that
went into the ACA, which

both sustains and
undermines that law,

but there remain often
largely invisible to us.

The other attack on the
status quo comes if you will,

from the left.

California’s ongoing
legislative attempt

to create a single
payer system has

gone the furthest in terms
of legislative progress

toward that end.

And we will hear about that
effort in today’s second panel.

And of course, this past
week Senator Bernie Sanders

of Vermont unveiled his
Medicare for all proposals.

Just as important, an
unexpectedly large number

of Democrats, including senators
and presidential hopefuls

for the 2020 contest have
now signed on as co-sponsors

to Senator Sanders measure.

So much so that some
are describing Medicare

for All, or another
a version of single-payer,

as a new litmus test for
the upcoming democratic

presidential primaries.

We shall see.

There are, it is worth
noting, potential tensions

between California’s plan
and the Sanders’ plan.

But clear momentum is
evident for some form

of universal government
sponsored health insurance.

Today’s second panel
will demonstrate

that alternative
models for health care

are incredibly
diverse and force us

to confront immensely
tradeoffs and challenges.

Single-payer has
no single meaning

in exactly how it
is designed, which

means exactly how
it is politically

shaped means everything.

Before turning the panel
over to Dr. Ben Sommers

I want to thank my co-organizer,
Dr. Janet Rich-Edwards.

Janet is co-director
of the science program

at the Radcliffe Institute.

She’s an associate professor of
medicine at the Harvard Medical

School, director of
developmental epidemiology

for the Connors
Center at Women’s

excuse me, for women’s
health and gender biology

at the Brigham and
Women’s Hospital,

and an associate professor
in the Department

of Epidemiology at the Harvard
TC Chan School of Public Health

where she also co-directs
the reproductive perinatal

and pediatric
epidemiology track.

I’ve come to know Janet
over the last five years,

and I learn something
new every time

we speak, not just
about health and science

but about professionalism.

Janet, thank you.

I want to thank Dean
Elizabeth Cohen and her staff

in the dean’s office for the
support of this symposium.

I want to thank Rebecca
Wassarman, Sean O’Donnell,

Jennifer Birkett, Kristen
Osborne of Academic Ventures,

and Jessica Vicklund
and the fantastic events

team at Radcliffe for
the way they put this on.

Our first panel, Functions and
Dysfunctions of the Affordable

Care Act, is moderated by
Dr. Benjamin Sommers who

is Associate Professor of
Health Policy and Economics

at the Harvard TH Chan
School of Public Health.

Ben?

[APPLAUSE]

– Good afternoon.

I am going to do very
brief introductions

of my esteemed panel here.

You have the full
bios in your program

and there’s a lot to
read about each of them.

But we’re very lucky to be
joined by Andrew Campbell who’s

a Professor of Political
Science at MIT,

Kate Walsh who’s is the
President and CEO of Boston

Medical Center, and
Georges Benjamin who’s

the Executive Director of
the American Public Health

Association.

And our panel
session topic today

is Functions and Dysfunctions
of the Affordable Care Act.

Conveniently that’s
basically what

I’ve spent the better
part of the last six years

studying, along
with my colleagues

at the Harvard School of
Public Health and elsewhere.

And so I thought to lay
the groundwork a little bit

for the discussion
that will follow,

I’m going to describe
some of those key findings

in terms of what is working
and what isn’t working.

Dan already mentioned
that the single highest

item on the list
of what is working

is that the Affordable Care
Act has been the largest

expansion of health
insurance in over 50 years

and has brought the rate of the
uninsured population in the US

to the lowest it’s been since
the federal government started

tracking this number.

Roughly 20 million Americans
have gained health insurance,

primarily through
three mechanisms.

One is the expansion of Medicaid
to low income populations

who traditionally didn’t
qualify for Medicaid.

And that’s only been adopted in
31 states plus Washington, DC

since the Supreme Court
made that an option.

There’s also the health
insurance marketplaces

that offer private insurance,
subsidized based on income,

where people get tax
credits to help them afford

private insurance
if they don’t get

health insurance through work.

And then finally for young
adults up through age 26

they’re able to stay on
their parents’ plans, which

was not generally available
prior to the Affordable Care

Act.

Now what has that
coverage meant for people?

In a series of studies
that have been conducted

using a variety of
data sources, we

can really get a picture of
what this health insurance

expansion means for people.

First off when you look at
just broad national trends

and national surveys, you see
that as coverage has expanded,

fewer Americans have said
they can’t get the care they

need because of affordability.

They can afford
the care they need.

They’re more likely to have
a source of primary care.

They’re more likely
to have access

to medications that they need.

If you look at prescription
claims that are filled,

we see increases,
particularly in states

that have expanded
Medicaid, in coverage

for drugs that are important
for chronic disease management,

things like diabetes and heart
disease and mental illness.

We also see improvements
in how people feel.

We actually, in
several studies, have

found that the expansion of
coverage under the Affordable

Care Act has lead patients
to rate their health

as having improved.

And again, the
strongest evidence

has been from the study
of Medicaid expansion.

Now why has so much evidence
been produced on the Medicaid

expansion?

We have a natural experiment.

Since it is up to each state, we
have 32 examples of expansions

and 19 nonexpansions.

And those comparisons
have been really

valuable in letting
us understand

what’s at stake with
these coverage gains

and what it means
for people’s lives.

Now what hasn’t worked as
well– and I could go on

much longer about how this
coverage means benefits

to people’s lives.

But in terms of thinking about
the dysfunctions of the ACA,

there are a couple of
points I’d like to make.

The first is what many of
you have probably heard about

in the lay media, which is the
notion that the marketplaces

are not stable and that
they are collapsing–

as our president often says–

has a kernel of truth
to it and mostly a lot

of rhetorical exaggeration.

So what we know is that the
marketplaces have generally

been stable in most
parts of the country.

But there are areas
in the country

where there are only one or
two insurers participating.

That has implications in
terms of higher premiums,

and it also means that people
have fewer choices when

they’re shopping.

That doesn’t mean that they
don’t have any coverage

options at all.

And to date, even though there
have been some near misses,

every county has ultimately
been able to offer insurance

to people on the marketplaces.

Now the coverage gained
through the marketplace

differs quite a bit
from the coverage people

get through Medicaid, in
particular in the form

of higher cost sharing.

The marketplace plans
typically feature deductibles

that can be several
thousand dollars,

and the most commonly
chosen type of plan

is only, by law, supposed
to cover 70% of costs,

meaning people pay
30% out-of-pocket.

Lower income people do
get some subsidies to help

that become more affordable.

But clearly this still
leaves some barriers

in affordability
for many people.

And so how do you
square these two pieces

of what I just told you?

Well, the first is
talking about what

has the ACA done compared to
the status quo prior to the law?

The second is that
there are still

significant areas of concern
and significant barriers

for some people under
the Affordable Care Act.

Now even more
notable than the fact

that some people
who have coverage

that isn’t quite
affordable is we also

have 3 to 4 million low
income adults in the 19 states

that have chosen not
to expand Medicaid,

and they simply have
no affordable option

for health insurance.

And if you think about
state-by-state variation,

it’s illustrative
to know that if you

are a single parent in Texas,
your income has to actually

be under $6,000 a year,
as an approximate,

to qualify for Medicaid.

If you’re earning $7,000 or
$8,000 as a single parent

you are too rich, in
many cases, for coverage.

If you have no
children in your home,

it does not matter
how poor you are.

Unless you have a disability,
you won’t qualify for Medicaid.

Now beyond the choices
of Medicaid expansion,

the broadest dysfunction
that some people

view in the Affordable
Care Act is simply

that even if it had
been fully implemented

without any challenges in the
courts and any state level

opposition, there still would
have been an estimated 20 to 25

million people without health
insurance when it was all

said and done.

The ACA was never intended
as a universal coverage bill.

You might argue that that was
not a dysfunction of the ACA

but a dysfunction of
the political system

or the realities of what
the political system was

able to produce given,
as Dan described,

how many near-death experiences
even this law went through.

But that’s where I think
the debate has shifted

on the left in recent
months, which is not simply

trying to improve the ACA but
looking at the 20 to 30 million

who don’t really have
any prospect for coverage

even with a more
stable marketplace

and even if we can coax more
states into expanding Medicaid.

So I look forward to discussing
these in more detail.

And now I’m going
to turn it over

to the first of our
panelists, Dr. Campbell.

[APPLAUSE]

– Well good afternoon everyone.

I’m delighted to
be on this panel.

And many thanks
to the organizers

for inviting me and thanks
to the Radcliffe leadership

and all the many people
it takes to put together

an event like this.

As the political
scientist on the panel,

I wish to focus on the theme of
citizenship, part of the larger

initiative that
Radcliffe is undertaking

for the next couple of
years, and in particular

how public policies,
including the ACA,

shape citizenship for Americans
and their ability, desire,

and likelihood that
they’ll participate

in American governance,
because participation

is one of our fundamental duties
as citizens in a democracy.

So I’ll talk today about the
political effects of the ACA

and the threats to the ACA.

And in doing so, we’re
going to take a brief walk

through some political science,
brief only, and then talk

about the implications
of the ACA.

And in doing so I’m going
to use the lens of policy

feedbacks, which
is a perspective

within political science
that sees public policies

not just as the outcomes
of political processes

but also as inputs.

That is that existing
public policies

change the political environment
through their effects

on budgets, through their
effects on ideas about what

good policy is, what
appears to work or not work,

through their effects
on interest groups–

some interest groups are
elevated by public policies

or by a particular policy
while others are sidelined–

and what I’ll focus
on today which

are policies’ effects
on ordinary citizens,

because policies affect
people’s views about government

and how effective it is and what
role it should play in society,

and because policies
affect individuals

likelihood of participation
and their likelihood

of participating in the face of
threat as we saw this summer.

So what drives
political participation?

Well people are more likely
to vote, contact elected

officials, work on
campaigns, protest,

go to town hall meetings,
make contributions

when they want to, when
they’re interested in doing so,

and when someone has
asked them to do so.

That is, do they have
enough resources to get over

the many humps and
hurdles in our society

to political participation?

Are they engaged enough in
politics to make that effort?

And are they mobilized
to participate?

And public policies can shape
all three of these factors–

resources, engagement,
and mobilization.

But whether policies have
these participatory effects

and whether those effects
are positive or negative

depends on several factors.

The level of
resources they convey,

are they significant to get
people over those hurdles

to participation?

Do they provide enough
financial security

so that people can
engage in politics, which

is really a luxury activity?

The visibility of
government effort–

can you even tell that you’re
in a government program?

Some programs are more
submerged or hidden than others.

There’s also the
issue of the messages

that policy designs
send to citizens.

Are recipients of
public policies or those

on the receiving
end, are they treated

respectfully and fairly, or
are they stigmatized or subject

to gatekeeping and to scrutiny?

And are there any entities
or information channels

that are mobilizing people
around a policy area?

Or perhaps in some
cases could a policy

be so important to people’s
well-being they can, in a way,

self-mobilize?

So let’s consider the
politics of health reform,

the Affordable
Care Act, in light

of these policy feedbacks.

We saw this repeal
and replace effort,

in particular the Republican’s
American Health Care

Act of 2017, this
summer was defeated.

We saw a groundswell of
political participation,

of grassroots activity, which
exerted considerable pressure

and played a major
role in pushing back

against this repeal effort.

So what elements
of the ACA may have

helped spur this
participation, and what

are the prospects
for ACA’s survival?

Because as Dan noted,
it’s an open question.

So it’s not at all
clear from the outset

the ACA would have enhanced
political participation

among the population.

First of all, as
you know, the ACA

was not all that popular
until the repeal effort.

It was hovering under
a 50% approval rating.

It was not at all
clear that Americans

would rise to defend it.

Supporters of the
law had always hoped

that as people
experienced the benefits,

they would become
more supportive.

But many beneficiaries felt
that health insurance was still

too expensive, even
after the reform.

Those people who had
employer-based insurance

had a tendency to attribute
problems or premium increases

in their insurance to the
ACA, with varying degrees

of justification.

So there are some design
elements of the ACA

that might enhance
participation.

Many of the benefits in the
ACA went to the middle class,

people who are more likely
to participate in politics

who traditionally have more
voice than, say, lower income

citizens.

So for example, the subsidies
for those purchasing health

plans on the marketplaces,
those subsidies

went far into the
middle class, up to 400%

of the poverty level,
which is around $88,000

for a family of four.

The dependent care
provision, the provision

that allows children to stay on
their parents’ health insurance

until age 26, that too is a
big help to the middle class

and affluent, the
kinds of people who

are most likely to have the
employer-based insurance

to put their kids on.

The ban on preexisting
condition exclusions–

well that’s a boon to
people of all income levels.

About a quarter of
Americans have some kind

of preexisting condition.

And preexisting conditions
tend not to recognize

the boundaries of income.

And other regulations, such as
the list of essential health

benefits, also helps everyone.

So there are quite a few
provisions in the ACA

that were benefiting
people who traditionally

have relatively more voice
in the political system,

middle class people,
upper income people,

more so than lower
income citizens.

On the other hand, there
were aspects of the ACA

that might serve to undermine
political participation

or at least not boost it, either
because these provisions helped

groups that traditionally
participate in politics at very

low rates or because
they were provisions that

were pretty hidden from view.

So much of ACA’s insurance
expansion, as you know,

operated through the
expansion of Medicaid.

But of course, it’s
been mentioned,

19 states decided not
to expand Medicaid.

And so that didn’t boost the
pool of potential defenders

in that there.

Also, much of
Medicaid, including

those who are newly eligible,
many of the aspects of it

were pretty hidden.

So some states, in an effort
in part to reduce stigma,

call their Medicaid program
something other than Medicaid.

Even here in Massachusetts,
it’s MassHealth, right?

In Oregon, there’s the
Oregon Health Plan.

In Tennessee, there’s TennCare.

A number of states have
these alternative names.

And studies show that in those
states with alternative names

to Medicaid, there is
in fact less stigma

associated with Medicaid.

But also, people are less likely
to recognize their in Medicaid.

They’re in something else.

Another element
of program design

is that most states these
days require most Medicaid

recipients to be in
a managed care plan

in order to minimize costs,
you know, an HMO, PPO,

some kind of managed care.

So sometimes you get
an insurance card

that still says Medicaid on it.

But often you get
an insurance card

that has the managed
care plan’s name.

And there again,
studies show that people

with these insurance cards
that don’t mention Medicaid

are less likely to know
that they’re in Medicaid.

And they also
participate in politics

at lower rates than
people in states

where Medicaid insurance
cards still say Medicaid.

Another sort of
hidden aspect of ACA–

think about the
under 26 provision.

Well, that helps the
middle class, as I noted.

But young people themselves
tend to vote and participate

in politics at pretty low rates.

And work by political scientist
Jacqueline [INAUDIBLE],,

who got here PhD from here
in the Government department,

shows that young people
who were newly covered,

newly got insurance
under this provision,

were no more likely to
participate in politics

afterwards than those who hadn’t
been covered by this provision

or themselves earlier in life.

So we had these sort
of two sets of factors,

some that might
enhance participation,

some that might
undermine participation

or at least not boost it.

It’s not clear at
all what the balance

would be regarding the ACA.

So far what we’ve found–

well, some scientists
have compared counties,

comparing counties
at state borders

where one side of
the border, the state

expanded Medicaid,
and the other side,

the state did not
expand Medicaid.

But otherwise, those residents,
the local economy, et cetera,

is very, very similar.

And they found a
mild positive effect,

that those people on the
Medicaid expansion side

were voting, doing voter turnout
at slightly higher rates.

And the effects were largest
in the poorest counties.

So that’s a positive
effect of ACA.

On the other hand, we also
know that ACA, as noted,

often provided health insurance
to low participation groups

or in a hidden way.

And there was a really
heartbreaking story by Sarah

Kliff, the wonderful health
expert reporter, on Vox,

talking about Kentucky and its
health care exchange, kynect,

K-Y-N-E-C-T. So Kentucky had
a very high uninsurance rate

before the ACA.

It’s the state that had the
biggest decline in uninsurance,

because of kynect and
vigorous outreach efforts.

But those outreach efforts–

you know, this is a state
where a lot of people

are skeptical about government.

And when some people considering
signing up for insurance

would approach navigators, they
would say, is this Obamacare?

And the navigators would
say, no, no, it’s kynect.

And then when the
law is threatened,

the same people
would say, oh, we

don’t have to worry
about Obamacare repeal

because we’re in kynect.

So there are downsides to hiding
the origin of these things.

Then came the Republicans
repeal effort.

And there’s few forces with
as much mobilizing potential

as threat.

Psychologists have told
us about the asymmetry

of gains and losses.

It’s very hard to take
something away from people.

People value losses more
than equal sized gains.

And with the threat of repeal,
the popularity of the ACA

finally rose.

It broke 50% for the first time.

People turned out at
town hall meetings,

called congressional officers,
in general raised hell

and helped push back
the repeal effort.

And in threatening repeal,
Republicans essentially

succeeded in making
the invisible visible,

two things in particular.

Much of the ACA works
through regulations.

Think about the list of 10
essential health benefits.

It’s hard to appreciate that you
now have coverage for something

that you didn’t know you
didn’t have coverage for

before until it’s
going to be taken away.

Medicaid– Republicans
have wanted for decades

to end the Medicaid entitlement.

Medicaid is jointly
funded by the states

and the federal government.

The federal government
sends its matching dollars

to cover all the people
that states deem eligible.

Republicans hate this.

And I think it’s because
in their proposals,

they have a serious
misconception about who

is in Medicaid.

And the repeal threat
brought to the fore

all these groups that
remind us there’s

lots of people in
Medicaid who are not

the people the Republicans
are thinking about.

The republicans are
thinking that, oh,

a lot of people in Medicaid
could, if they wanted to,

go out and get a job with
employer-provided insurance.

Not so easy, because
some of those people

literally can’t work.

And there are many
parts of the country

where it’s hard to get a
job with health insurance.

When the threat came
along this summer,

we heard from all these
other groups within Medicaid,

families with disabled elders,
former middle class people who

had run through
all their resources

and now need Medicaid to pay
their nursing home or home

health care, even
more potent, parents

of disabled children, physically
or cognitively disabled

children who are in Medicaid,
again, a lot of middle class

people who can’t otherwise
afford their children’s

incredibly expensive care,
families of people seeking

opioid addiction
treatment, again oftentimes

middle class families who faced
a tragedy for which Medicaid

is a crucially important pair.

And all of these people would
be harmed by Republican efforts

to turn Medicaid
into a capped program

and strip out $800
billion in funding.

And who were the protesters–

I’m happy to say– at
Radcliffe Institute?

As Theda Skocpol has
pointed out, in many cases,

it was women who organized and
rose up to fight the appeal,

because women are still
disproportionately health care

decision makers
in many families.

They tend to be the
caretakers in families.

And they’re very aware of the
toll that repeal would impose.

So I’ll just close
with a few observations

about prospects for the future.

The fight is far from over.

And now what concerns me is that
the current attacks on the ACA

are not the visible repeal
attacks from Congress.

They’re the invisible
administrative attacks

from within the executive
branch, the defunding

of navigators, the cessation
of advertising for those who

might newly sign up this fall.

They’re sowing doubt
and uncertainty

so insurers will pull
out of marketplaces.

And my concern is
that the citizens who

mobilized against the visible
repeal efforts this summer

won’t recognize or
know about or be

aware of these other
more insidious kinds

of administrative actions that
will be just as effective.

So that’s what I’m really
concerned about now,

is the nature of the
current dismantling

being much more hidden
and not resulting

in action among the public.

And then the very last
little normative comment

I can’t resist since someone
brought up federalism.

I have a lot of colleagues
who study social policy

in other countries.

And they cannot believe that
in the United States you would

have an uninsurance rate of
4% in Massachusetts and–

well, now it’s– 18% in
Texas for the under 65 group.

So think about all the
people in this room.

A couple of hundred
people, right?

Only 4%, 4 out of
100 of you would

be without insurance
in Massachusetts.

In Texas, it’s one out of every
five people, you, and you,

and you.

I mean, it’s a lot of people.

What could such variation
possibly achieve?

It raises a lot of questions
in our federal system, which is

very useful in many, many ways.

But this kind of variation,
is it responsive?

Is it effective?

Is it moral?

So I will leave you
with those thoughts

and look forward to my
fellow panelists’ comments.

Thank you.

[APPLAUSE]

– Hi, everyone.

Thank you.

It’s so interesting to hear
about what you do every day

through a different lens.

I really enjoyed your talk.

Thank you, Andrea.

So I’d like to talk a
little bit about citizenship

from the standpoint
of an institution,

or institutional citizenship,
and talk a little bit

about what I think of as sector
or health industry citizenship,

particularly as it relates
to the Medicaid program.

We’ve talked a lot
about expansion.

But just know that the biggest
part of the expansion–

I think some of the speakers
have highlighted this–

has been in the Medicaid
program across our country.

So I’m going to focus on
that, and from the standpoint

of our organization, which
is Boston Medical Center.

I will do a brief
introduction, I

promise, talk a little bit
about this sector obligation,

tell you a little
bit about where

I’m hopeful about how health
care reform and Medicaid

reform in Massachusetts
can benefit

not only our institution,
but the patients that we’re

privileged to serve,
and why I think

we can be successful at this.

So I promise a
brief infomercial.

But we’re in a very
historic place,

and I thought I’d chat a
little bit about our hospital.

We were formed about 20 years
ago, a little longer than that,

by the merger of what was then
Boston City Hospital, which

had had a long and distinguished
history– it’s been around

since before the Civil War.

I like to say to people, from
President Lincoln to President

Trump, our organization’s
had the same basic problem.

And the Historians
like that joke, OK?

And we were formed by a
merger of what was then

Boston City, as I said, and
University Hospital, which

was the Boston University School
of Medicine’s primary teaching

affiliate.

It was spun off to form
a separate 501(c)(3),

like any other charitable
not-for-profit hospital you

might know of in
the Commonwealth.

Sometimes people still think
of us as City Hospital.

I’m here to tell you, Uber
drivers and cab drivers

think of us as City Hospital.

But in fact, we’re just
like everybody else.

I think we are unique
in that we were created

through enabling legislation.

And you can see at the
bottom of the slide

that it talks about BMC.

It was to be the centerpiece
of the city’s public health

network.

And I’d like to
think that that’s

a very prescient and
important part of our mission,

because you’ll see we’re
evolving towards that as we

move forward.

This is a picture of
our hospital today.

You can see that we’ve kept
some of the older buildings

that were around in 1864
or shortly thereafter

and built a new cancer
center– is what you’re

looking at in front of us.

Our mission is clear.

We provide exceptional
care without exception.

We’re very proud to
support that mission.

I’ll tell you a little
more about that later.

And our vision is
“to make Boston

the healthiest urban population
in the world by the year 2030.”

We’ve really shifted
our focus from dealing

with the episode of illness
to the health of the community

we serve.

That is to me
institutional citizenship.

I hope it works.

I hope I’m around to
talk about in 2030,

probably won’t be, at
least in this role.

But that’s kind of how
we’re thinking about it.

Just a little bit
about the numbers,

because this is a bold vision–

how do you think
we can get there?

We’re a large hospital.

We take care of lot of people.

We do over a million
ambulatory visits a year.

We’re kind of known for trauma,
and are the largest provider

of trauma in the region.

We’re very proud to be
associated with 14 community

health centers that are across
Boston in the neighborhoods

that we serve.

We are the third
largest health system

in Massachusetts, which
always surprises me

when I say that, because we are
not the third richest health

center or health system
in Massachusetts.

And one thing you
might not know about us

is that we own and operate a
Medicaid insurance plan that

brings peace of mind
and access to patients,

to our members in Massachusetts
and now New Hampshire.

So we’re on the
Obamacare exchanges.

And we’ve been very active in
the Medicaid expansion space.

We disproportionately
serve low income patients

70% of our patients are
underserved or underrepresented

minorities.

30% of our patients
don’t speak English

as their primary language.

That number’s on the increase.

We do about 200,000
translator-assisted medical

encounters every year.

And half of our patients
are eligible for Medicaid,

which means that they’re at
the federal poverty limit.

About 79% of our revenue
comes from government sources.

So we kind of have
to get this right.

Reform is kind of our work.

You know, health care
is really complicated.

And I could really
literally bore you to death

up here all day with all of the
arcane nuances of how we get

paid and where the money goes.

But one of the things I’m very
proud about Boston Medical

Center is that we’ve really
come up with practical solutions

to really complicated problems.

About 15 years ago, a
third of our patients

were screening positive
in the pediatric emergency

room for food insecurity.

Why?

Because we asked.

What did we do about it?

We got them food.

So we set up what we call
a therapeutic food pantry.

Your doctor or nurse, if
you identify food insecurity

in your home, can write
you a prescription

for a three-day
emergency supply of food.

It provides.

It’s for your household.

You know, it addresses the
kind of episodic hunger

we see in this country.

Your benefits run out
at the end of the month.

Your uncle loses his job and
is sleeping on the couch.

The food dollar
doesn’t stretch as far.

We started serving 500
families, moms, and kids.

We now serve 7,000 people every
month a million pounds of food.

And it’s a prescription.

It’s in your electronic
health record.

So when you come
to see the doctor,

he or she knows that you’ve–

you know, here’s your
prescription for insulin.

Here’s your
prescription for food.

We know in the food pantry
about your dietary restrictions.

And we also know
when you don’t come,

which is particularly
important to frail, elders,

people who are too proud.

And we’ve added to this a–

it reduces some of
the stigma around–

you know, you have
to swallow your pride

to go to a food pantry.

And we’ve made this a real
focus of the work we do.

I’ll talk a little
bit later about some

of our other programs.

But one I love to talk about
is our Jump Rope Clinic.

So a lot of kids in
our pediatric practices

are at risk for
childhood obesity.

It’s kind of
becoming an epidemic.

And a lot of the moms
say, look, but I don’t

want my kid going out to play.

The neighborhood’s not safe.

So we give them a jump rope.

It costs $0.79.

And before they leave, we time
how many times you can jump.

And then we call back
a couple of days later,

say, hey, how are you
doing with that jump rope?

I mean, it’s not going
to solve the problem.

But it’s these kind
of practical solutions

that I think represent
institutional citizenship.

I wish I could say
these were my ideas.

They’re not.

I just get to talk about them.

But I think that if
as organizations we

embrace our challenges
and our responsibilities,

I think we’ll be
better citizens.

Addictions is probably
the best example.

BMC sadly cares for lots of
people who are struggling

with substance use disorders.

We also are
celebrating recovery.

We are challenging
ourselves not only

to expand the kind of
programs that we deliver,

but also to be a
better employer.

Think about the
challenge when somebody

who has been in recovery
relapses, comes back to work,

and they’re taking care
of patients for their job.

What’s– Yeah, I’m
getting a lot of nods.

I don’t have to fill
in the blanks there.

What’s our responsibility?

Also, we’re a health plan.

What do we cover?

So it’s great for
me to say, hey,

we have all these
programs for our patients.

But what are we doing
as an organization?

I’ll skip that.

But it basically proves that
addiction treatments are

good investments
and that they work

and that they save health
care dollars, which

could be available to actually
provide additional treatment.

Because we know this
epidemic isn’t going away.

So this has kind of become
one of my favorite things

to talk about, which is
really why the health care

industry has to embrace
the Medicaid program.

And I’ll tell you, we don’t
as hospital executives or even

health plan executives do
a very good job of that.

And just to let
you know, Medicaid

is the most important
insurance plan,

I would submit, in
our country today.

It covers more
than half the kids,

more than half the births, and
pays for 70% of long-term care

treatments.

So we have got to get over
our ambivalence about this.

And I often joke that
fee-for-service Medicaid

is no way to make a living.

And I can get as frustrated
as any hospital executive

you’ll meet about the challenges
of living within the Medicaid

payment envelope.

But increasingly,
I think there’s

so much opportunity for us to–

and we have such an
intergenerational

responsibility to–
get this program right,

that it’s our obligation as
health leaders to save it.

So that’s my close.

I’ll close with that homily.

But it’s really–
and if you think

about the challenges
around the Affordable Care

Act and the
challenges to access,

if we could get Medicaid
right, and we could afford it,

think about the
disparities in our country

that it would help erase.

So if you think about trying
to get Medicaid right–

I’m going to shift a
little bit to this state,

to the state of Massachusetts.

But before I do that,
I’ll highlight the fact

that many states are looking
at changes to their Medicaid

program.

And several are adopting a
shift to accountable care

organizations.

So what this does is it attempts
to, in the simplest of terms,

align the incentives between
the payers, the people who

are paying for health care,
which is often the state

government, and the
providers, people

like the folks at our hospital,
and puts all of those dollars

at risk in one pot that the
health care system controls.

It’s going to be a very
interesting journey here

in Massachusetts.

We’re just starting
on that, where

we are converting to an
all-risk Medicaid ACO

in March of next year.

So stay tuned.

But the early returns from
other hospitals or, I’m sorry,

from other states, are
promising, in that there have

been some savings identified.

So I’m looking forward to our
role in being part of that.

So let me take a minute on how
our health system is preparing

for this change and why I
think I like our chances.

As you’ve heard, there
are many, many people

in the Commonwealth
of Massachusetts– one

in four people in this room,
if the statistics hold,

are– covered by MassHealth.

You stand in line at the
grocery store behind people

who are covered by MassHealth.

1.8 million people
in Massachusetts

are covered by MassHealth,
or the Medicaid program

as I’ve learned I
should call it now.

And that’s great because
it’s great coverage.

It’s a wonderful insurance plan.

But it’s 40% of
the state budget.

If you look at state
spending, health is up.

Every other category, education,
public transportation,

public safety, is down.

Medicaid can’t eat the
Massachusetts state budget.

And we are a well-off state
here in this Commonwealth.

So we’ve got to figure
out collectively

how to reduce the spend in that
program, get people healthy,

keep them well, do it at a price
point the state can afford.

So MassHealth his investing
in these accountable care

organizations.

They are focusing on making sure
that we do this in a way that

improves patients’ experience.

This is not only a cost play.

We will be as successful
in this program if we meet

their quality metrics as if
we meet the cost threshold–

although obviously
we have to do both–

strengthening the relationship
between the primary care

doctor and the patient,
not in the gatekeeper way

of managed care in
the ’80s and ’90s,

but much more in
an integrated way.

And I talk a little about
clinically integrated provider

networks on the next bullet.

And then finally, we
have to as an industry

learn that the body
does not stop here,

that integrating behavioral
health into physical health

will, I think, be the key
in unlocking our ability

to reduce suffering,
reduce costs,

and making
communities healthier.

So why do I like our chances?

Because I really like the
place I work, I guess.

I think the key is going
to be a rigorous focus

on the social
determinants of health.

This is the talk of the day.

Everybody talks about it.

We’ve been doing
this for decades.

I’ll give you one.

I talked about the food pantry.

We’ve put a small portion
of our balance sheet

to work on transitional
housing through a REIT that

will help us get transitional
and assisted housing

into the neighborhoods we serve.

And I’ll tell you one story
about financial stability,

because I’m so proud of it.

Two of our a pediatric
residents realized

that many of the
families they served

were missing
opportunities provided

to them through the
Earned Income Tax Credit.

And they said,
wouldn’t it be great

if we could have
accountants help

our families do their
taxes while the kids are

being seen at the clinic?

And great idea– they’re not
giving the money to H&R Block

or any of those other places.

I didn’t mean to pick on them.

Well, they started the program
with the unfortunate hashtag,

“see the doc, get
cash,” which is illegal.

So after we took down
the Twitter handle

and straightened things out
and resuscitated the compliance

people, that
program has returned

over the last two years
over a million dollars

into the communities we serve,
including many BMC employees

who were eligible for this.

Two residents, two citizens,
had a really good idea.

And they were able to do it.

That just– I mean, I have
chills talking to you about it

because that to
me is citizenship.

And that’s what’s
going to save us.

So I’m very proud of this.

We decided– we’ve worked really
hard on our energy initiatives.

And we’re going to be totally
carbon neutral by 2020, which

I got to knock wood on that.

But I think we’re close, through
a long, complicated story which

I’ll spare you.

But one of the things we did
was– you know, one of the ways

to cool buildings is to
put a garden on the top.

And we were going to put just
kind of a pretty flower garden.

But no one was going to see it.

And somebody–
again, I think it was

the assistant of
the guy who runs

our facilities program–
said, what if we do a farm?

So we have a farm on the
roof of our power plant.

Each of those little–
well, you can’t see it,

but it’s in– milk crates is
going to produce 50– it will,

has produced this
summer 15,000 pounds

of food for the patients
and families we serve.

It’s unbelievable.

There’s 100,000 bees
up there, so don’t

visit if you have an allergy.

But it’s really just
a remarkable story.

Somebody had an idea.

We figured out how to do it.

It’s great.

The farm’s a great start.

But I think the real
challenge here–

and I think we will get
this right as citizens–

if we can really focus
on health equity.

It’s great to be
in Massachusetts.

We’re in a state that has
built a little square box

for everybody.

Pretty much everyone has access
to health care in the state.

I’m very proud to work
at an organization that

will build you another
box if you need it,

if this metaphor
works, to see the game.

But I think that our
challenges in health care

will be solved when
nobody needs a box.

Thank you very
much for your time.

[APPLAUSE]

– Well, thank you very much.

I’m going to just
build on the fact

that some of the comments
you’ve heard earlier

about what role of government
is, because I’ve always–

I often get asked that.

Why does government want
to intervene at all?

Why is this the
government’s business?

Why can’t the private sector
take care of all of this stuff?

And I have often said they
are really for reasons

that government intervenes,
obviously the safety and public

welfare of its citizens, when
moral or ethical issues are

involved, obviously politics.

You know, governments are
political institutions,

so politics plays a role.

But also when you have a
market failure, you know,

that’s why we
intervened in the banks.

And I would make the
argument that the reason

we went to the
Affordable Care Act

was because we had failure
in all four of these areas.

The government
needed to intervene.

And that’s why health
reform was essential.

Also the point is that
we now know of course

that we don’t get the best value
for our health care dollar.

I expect everybody in this
room has at some point

seen this particular graphic.

But if you think
about it, it basically

means that we pay
almost twice as much

as the other industrialized
nations and we die sooner.

The Commonwealth Fund
just recently pointed out

four core reasons why we
have these differences

than other nations, the fact
that we’re the only nation that

doesn’t have universal
coverage of all our citizens

for health care, the
fact that we spend

a lot more of our
focus on the treatment

side than the prevention
side, that we spend

a lot more on things other
than our social determinants,

and the fact that we have one
of the most complex systems

in the world, both for
the delivery of care

as well as the
financing of that care.

I remember when I was
Secretary of Health in Maryland

the amount of time we spent
measuring the transferring

from the left pocket to the
right pocket for Medicaid

and Medicare, just trying to
balance those and making sure

that we were doing it right.

We also as a nation
spend much less

on social services
versus health.

And so if you just look at
our social services and health

budgets, there’s an
enormous imbalance there.

And people always ask, where
can the money come from?

Well, obviously if
you do a lot better

on the health side
of the equation,

you have a lot more money
for social services.

Now, the ACA was designed
to properly address

these five things.

Expand coverage.

Try to move this system
up towards prevention.

To some degree, do some things
about the social determinants.

And I’m going to talk
a bit about that.

Reform the delivery
and the payment system

to try to make it simpler, so
that we simply are not only

paying for volume, but we are
actually paying for quality,

and ultimately,
to make it cheaper

for both the whole system as a
whole as well as individuals.

Ultimately, the goal of course
is to improve health outcomes.

Now, clearly access to care
is very important, right?

We’re in an
insurance-based system.

You have to have a get
into the system card.

We often hear from
people who believe

that the fact that we have
emergency departments–

that you have
universal health care

with emergency departments.

My first half of my career was
practicing emergency medicine.

I can assure you that
emergency departments

don’t give a universal
access to care at 3 o’clock

in the morning.

There has never been a
person that I referred

that the first question as part
of that referral discussion

wasn’t what insurance does
that patient have, OK?

The other thing about
emergency departments of course

is that while we can fix you and
make you better than you ever

were before–

we’re really good at that–

emergency departments
don’t take care

of the things that
actually really impact

our health or our
health care spending.

We don’t manage a
little bit of high blood

pressure, a little bit
of high blood sugar.

We don’t do that.

A little bit of obesity,
that doesn’t get

fixed in the
emergency department.

That only gets fixed with
comprehensive primary health

care.

You know, the whole issue
of paying for performance

is very, very important.

And you know, that’s
very much at threat now.

There is a lot of regulations
being changed that actually

undermine that right now.

We need to address that.

I would also argue
that of course health

is much more than health care.

That’s the social determinants
that we always talk about.

But I think the more
important manifestation

of that is your zip
code fundamentally

determines your access to
a whole range of things.

Now, we see this, right?

In every town in our country,
there is a railroad track.

And on one side of
the railroad track,

the population does better
than people on the other side

of the railroad track.

Or it’s a Main Street.

Everybody has one of those.

And that same dynamic applies.

It’s a fascinating phenomena.

But it dramatically
determines your health.

And there’s all kinds of
reasons that we have systems

that we’ve designed this way.

But we really designed
our communities

in many ways for failure
for some crazy reasons.

The ACA was actually designed–

and we hear a lot
about coverage.

And so as Executive
Director of APHA,

I have to talk about population
health and prevention.

So we’re going to just talk
a fair amount about what

was in there that people just
don’t talk a great deal about.

There was a lot of stuff
around clinical prevention,

the first dollar insurance
coverage, clinical preventive

services as essential
health benefit,

much emphasis on improved
disease management,

some real enhancements to
the primary care system,

to try to move our system
upstream, including

actually paying at least–

although it expired– primary
care providers Medicare rates,

to try get them engaged
more into the system,

and some things that ultimately
are in the legislation

but they weren’t funded,
like a workforce board

to look at the rebalancing
of our workforce.

Things like that are
very, very important.

And there are some things
about community prevention,

the National Prevention
Council and Strategy.

That was headed by
the Surgeon General.

That actually was enhancing
our nation’s ability

to work across silos, not
just at the federal level,

but also that was trickling
down to the local level.

The Community Preventive Health
Task Force and their work

research was funded.

So that task force
could do its work,

improve the evidence base for
community-based interventions.

The community health
needs assessments

that hospitals are now
required to do– in fact,

enhanced enforcement
by the IRS was

essential to try to
make that happen.

And there are a whole range
of health education activities

like menu labeling
and things that we

can do to enhance patients’
engagement in their own health,

and some things that were
fundamental around health

equity.

You know, you can’t do
what you don’t measure.

You don’t know what happened
if you don’t measure it.

So measuring health
equity, acquiring data

collection, targeted programs
on health equity like the REACH

program, were funded
out of this grant,

even though those
programs existed

before there was an
enhancement on trying to get

those programs up and running.

The Public Health
and Prevention Fund,

which was supposed to be
ultimately a $2 billion

investment in public health
and prevention innovation–

public health has obviously
been chronically underfunded

for many years.

Only 3% of our health
care dollar goes there.

But it’s been under attack since
it first came out, crazy, stuff

crazy arguments as
to why we should not

do this kind of
preventive health stuff.

The one that’s
most obvious to me

is the argument
that we shouldn’t

build safe places
for kids to play

and that that wasn’t a good
use of health care dollars.

It’s the most
amazing thing to me.

The data is real
clear that children

in organized, structured
play do better physically,

have better mental health,
and get in trouble less.

It’s just amazing.

But they’re still
trying to remove this.

Every bill gets passed,
they put in a measure

to try to get rid of
the prevention fund.

So it’s still at political risk.

And the whole idea
of building systems

across sectors to
improve health–

so I’m going to give you
my idea of how to do that.

So this says, you
think about asthma,

a common clinical scenario.

Asthma is a common
environmentally sensitive

disease.

Minorities are
disproportionately

impacted by this.

It is a significant barrier
to school attendance.

Dental is the other big barrier.

And if you really want
to understand the root

causes of this, you can really
address both clinical aspects

and social determinants
and craft broad solutions,

if you really understand what’s
happening in the community.

So put your epidemiology hats
on for a moment and your disease

detective hats,
and imagine a day

in which we have 10 kids who
all go into a hospital emergency

department on the same day.

And these kids all go
to the same school.

And they’re out of school
because they’re sick.

And they’re sick enough of
course to go to the hospital.

But no individual hospital
is going to pick this up,

because the numbers
are so small.

Now, if this was measles or
some other infectious disease,

the health department
would be all over this,

because we have a system for
collecting that and doing

the surveillance and then doing
the disease management, case

finding, et cetera,
to address it.

But we don’t do that
for chronic diseases.

But this was an acute
chronic disease.

So imagine that we did this
on this particular day.

And you know, the health
department picked it up.

The private
hospitals reported it

in through their
various data systems.

The school knew that
they had 10 kids out

because they had 10
kids out of school,

and they knew they were
out because of asthma

because they had a
school health program

and the nurses there knew that
the kids were out for asthma.

And so we do the classic
epidemiological assessment

of this school.

The public health
department is notified.

They look at where they live.

They look at their
insurance coverage.

They go to their homes.

They do all the
kind of stuff we do.

We try to understand why
these kids may indeed

had acute asthma attacks
and that particular day.

And of course, what they
find is that all the kids

ride the same school bus.

The school bus has a broken
tailpipe, broken tailpipe,

noxious fumes.

Asthma sensitive kids
all get asthma attacks

and end up in the hospital.

So who’s the hero of the day?

Well, I would love to be able
to have the public health

system take credit for that.

We should take a little
bit of credit for that.

But the actual hero of the day
is the bus mechanic, right?

The bus mechanic goes up
and fixes all the tailpipes,

inspects all the
other bus tailpipes.

And you find lots of them
broken because they have not

being properly maintained.

And if you’re really good, you
do all the other maintenance

work that needed to
be found, et cetera.

But now you have
a system where you

had across sectors, the school
system, the private hospital,

the public health, and
the transportation system,

all work together, ultimately
reducing emergency department

visits, saving dollars,
improving health,

reducing school
absenteeism, theoretically

improving school performance.

And of course, the
transportation system

is much safer.

The ACA is actually designed
to craft systems like that

by funding outcomes
over quantity

and trying to build a
comprehensive system to address

our health, looking at having
the hospitals and others look

at what the needs of
the community are.

We want to put systems in place
that look something like that,

to try to ultimately
improve community health,

and measure what we do and
hold ourselves accountable,

and not just hold the
health system accountable,

but hold everybody accountable
for the community’s health.

And you’ve heard a lot
about the outcomes.

And I’ll just give you my
short list of those outcomes.

And these numbers are before
the recent census numbers,

which show that the numbers
aer even lower than that today.

But you are seeing reductions
in morbidity and mortality,

depending on where you live.

You’re seeing improvements
in 30-day readmission rates.

You’re seeing marked improvement
in preventive health services.

Costs are down all over.

Yes, I understand that there
are costs up in some areas.

I also chuckle when I
hear where they’re at,

because in most cases, these
are places where they have not

expanded Medicaid and not
paid any regulatory attention

on the cost of care.

And many of those
places only had one plan

to begin with before
the Affordable Care

Act was put in place.

And we’re seeing improvements
in our community funding

and activities from
these various grant

programs that we’ve had,
which was spun out of activity

from the Affordable Care Act.

So where do we go from here?

Again, taking the Commonwealth
Fund’s four big buckets,

the fundamental goal of
course is achieving coverage

for everyone in our
country, again markedly

moving our system up
to do more prevention,

addressing more and more the
social supports in our country,

whether it’s funding or
linking those systems

or redesigning
them in many ways.

And at the very least–

and we’re to have a
discussion in the next panel

about alternative models–

we’ve got to simplify the
system in service delivery.

I mean, we spend more
money making sure

that we reconcile
accounts between buckets

of money each and every
day, which absolutely

makes no sense.

And by the way, nobody else does
that in the rest of the world.

And then politically, the
short term strategy of course

is we hope the ACA
is dead for now.

I just read something
today about this new bill

they’ve put in place.

They think they might be
able to get to 50 votes.

We’ll do everything we can
to keep that from happening.

But at the end of the
day, after the end

of this month, and
the fiscal capacity

to move a bill through
reconciliation goes away,

we’re hoping that people
will roll up their sleeves,

buckle down, and come up with
some bipartisan solutions

to first stabilize
the exchanges and then

move on to improve coverage.

And of course, I’m always
interested in protecting

the prevention fund.

Fundamentally as a culture,
we need to create health

as a shared value.

And that’s the fundamental
problem we have.

Health is not a shared
value until we get sick

or a loved one gets sick.

Thank you.

[APPLAUSE]

– So we have a
little bit of time.

We’re going have a discussion up
here with members of the panel.

And I have a couple of questions
I want to pose to our panel.

And then we’ll open it up for
questions from the audience.

My first question/comment
comes from several

of the remarks made,
that all of you

addressed Medicaid, which
is an area that I have spent

a lot of my time working on.

And there is a clear
disconnect between the way

that policy elites and political
circles talk about Medicaid.

You hear White House
spokesman say, this is broken,

no one in the program
gets the care they need.

You hear senators who
basically routinely assume

that the program is broken.

And you hear–

I will say anytime I write
anything for a medical audience

that touches on Medicaid, I
get guaranteed angry e-mails

the next day from
doctors who tell me

how terrible the program is.

But when you talk to patients,
it’s actually quite popular.

And in some surveys,
it’s even more popular

than private insurance.

But generally, it gets
very high ratings.

And the studies are that the
overall care in the program

is quite good.

So how do we reconcile this?

And what does that imply for the
political mobilization related

to Medicaid, that there is this
big disconnect between those

running the system and
those living in it?

– Can I just– is this on?

Is this on?

I can’t tell.

– Yeah.

– Yes.

As a political
scientist, I’ll just

say that I think it’s because
those lawmakers infrequently

hear from the people who
are actually in the program.

And so they don’t hear
the firsthand accounts of,

Medicare is actually quite
comprehensive insurance

in many places,
covers many things

that Medicare and private
health insurance don’t cover.

And access is pretty good.

Access does vary across states.

The higher the reimbursements
are to providers in a state,

the easier it is for
citizens to gain access.

But I think it’s a matter
of just those folks who are

in Medicaid don’t–

you know, they have
very little voice.

You just don’t hear from them.

And people assume that if
it’s a government program,

it must be a bad program, which
is part of our sort of distrust

of government in
the United States,

which is obviously a theme
that undergirds so much

of American politics.

– The only thing
I would add is–

you alluded to it in
your opening comments–

it’s payment.

So if Medicaid’s paying
$0.64 on the dollar,

it gets up to about $0.75
on the dollar for us

after supplemental
funds, the money stuff.

But I think the–

that’s why kind of
I’m on this kick

off issuing this call to action
to save the program, because I

think the subtraction
experiment,

if you take away those
services and if kids–

if we have even more
disparities in health and birth

outcomes in this country,
if we don’t care for–

the fastest growing population
group in this country

is– people over the
age of 85, most of whom

are getting the services they
need through the Medicaid, not

the Medicare program, because
Medicare will pay for you

to have neurosurgery
but no one will

help you go to the
grocery store– that

would be a Medicaid payment.

So I think the
challenge really is

how we’re seen as– how we’re
reimbursed for those services

compared to other programs.

So I think it is an
intergenerational

responsibility that
we’ve got here.

And I think as health leaders
we have to embrace it,

that it’s not going away.

And we should really
understand the good it can do

and the [INAUDIBLE] and the flexibility

it provides us, if the
states would participate.

Massachusetts is
pretty good at that.

– You know, at the
end of the day,

I always remind you, like any
other thing, as a physician,

I respect my
colleagues and believe

that they went to medical school
and do what they do in order

to take care of people.

But at the end of the
day, follow the money.

Medicaid just doesn’t pay.

It’s just not the best
player in most cases.

– It’s the worst.

– Well, it depends.

In Maryland, which has
an all-payer system,

Medicaid pays exactly the
same as Blue Cross Blue

Shield for hospitals.

It does not do that
for physicians.

Although we’re moving in
that direction, by the way.

But it is a poor payer.

And the more
interesting thing to me

is when a governor
tells me, well, doctors

won’t participate in the
program, well it turns out

the solution is all in
the governor’s hands.

All the governor has to do
is raise provider rates.

And the way to do it
initially, and also

meet what I talked about
in moving to primary care,

is raise provider
rates from Medicaid

to Medicare rates
for primary care.

And it’s relatively
inexpensive to do that.

And that would, I would
argue, be the first step.

So you’ve got to
pay providers more.

The second thing, of
course, is the challenge

of taking care of patients
who have all these other life

challenges.

And yeah, some of
those patients, they

miss appointments.

They come in late.

I don’t want to
stereotype anybody,

but that’s the view of
some of these providers.

They view them as
disruptive to their practice

in a variety of ways.

But to me that means that if
you, like any other business,

have a large population of
clients, customers that require

certain other
things, you may want

to think about restructuring
your practice in a way

to manage them.

And the state can also
help with that process,

as can the medical societies.

– In terms of
federalism, I think

this is an area that is
particularly interesting

to look at from the
state perspective

that Ms. Walsh was mentioning.

When we look at the current
dynamic between the states

and the federal
government, those

who are feeling that federalism
is a system maybe that is not

providing value to us in
terms of policy returns,

probably five years ago might
have felt the opposite, right?

So what is the
value in federalism

when you’re in a
state that wants

to do something quite different
than the federal government?

As we see now, living in
Massachusetts under Republican

Party control in Washington is
quite different than five years

ago, when most of
the state had voted

for the candidate in office.

So I’m interested in your
thoughts on how federalism

might in some ways actually
be the saving grace for some

of the programs we’re talking
about in the current policy

context.

– Right.

Federalism– can’t live with
it, can’t live without it.

So as I said, it’s the promise
and peril of state variation,

right?

So on the one hand, the
wonderful thing about variation

is that when there are
differences in preferences

over the role and
scope of government,

you can have different levels
of services in different states.

And what’s interesting
about federalism

is that traditionally,
it’s been conservatives

who wanted local
or state control

and liberals who
wanted federal control.

But it turns out that those
ideological positions are not

static.

It depends on who controls those
different levels of government.

So that’s one thing.

One trend I’m concerned
about in federalism

is that we see a lot of what’s
called preemption, which

is within states you have–

well, obviously, we
have state variation,

which we’ve been talking about
today vis-a-vis the health care

system.

What we also see is
variation within states.

And so you’ll have
cities carrying out

policies that are different
than what the larger state would

carry out, minimum
wage for example,

or paid sick leaves in cities.

And what’s happening is that
state governments are engaging

in preemption, passing laws that
then say, cities in this state

can no longer their
own minimum wage laws.

And sometimes we also
have federal preemption,

the federal government saying
states can’t do their own thing

in a variety of policy areas.

And so for those who celebrate
the variation that federalism

can afford, this
preemption movement

is undercutting
federalism in ways

that are not favorable
to tailoring programs

to public opinion and
public preferences.

– I think I’d quote
my esteemed colleague.

I think it’s follow the money.

We have to ask
ourselves as Americans

why the federal government feels
compelled through the Medicare

program to basically cover
the costs of care for seniors,

but does not feel compelled to
cover the costs for low income

people.

They split it with the state.

I don’t know whether that–

I wasn’t actively involved in
policy discussions in 1965,

I’m happy to report.

But I think the–

so I don’t know
the answer there.

But I think it does
come down to funding.

I’ll take your comment about
preemption one step further.

There are often
dollars that come

into a state that are
designated for Medicaid,

and then they go to
the general fund.

That’s the story of
Connecticut, which

you would think of as a
relatively affluent state.

But the facts are they
are close to bankruptcy

and are using FMAP,
monies intended

to match Medicaid health care
expenses, for just general fund

purposes, to keep
the state afloat.

– You know, it’s funny.

I would argue that
as a national policy,

we should make sure that
everyone is covered and has

access to health care.

And when I talked about creating
health as a shared value,

that’s what I mean.

It starts with that.

And then everything
else is derivative.

You know, yeah, you could
devolve all the dollars

through the states, but
you’d have to trust them.

And their track record so
far is that some states have

done amazing things,
because they’ve

adopted that as a
principle, and other states

have used it to do
non-health things with it.

And it doesn’t matter whether
it’s health care financing

dollars or tobacco
settlement dollars, right?

I remember when the tobacco
settlement dollars came in,

some of the more progressive
states that really

were concerned about
tobacco spend their dollars

on tobacco programs and
other health programs.

Others gave them to
the tobacco industry.

It’s just the most
amazing thing.

And you know, it’s a value
of how those dollars are

going to be spent.

And it’s unfortunate.

– My last question,
and then we’re

going to open up
to the audience.

And we’ll start, Dr.
Benjamin, at your side

and work our way
back to Dr. Campbell,

so you don’t always
have to go last.

This is the issue of
prevention efforts

that are population
health-oriented, not

health care-focused and
social services-focused.

How do you build mobilizations?

And we have a leader of
a national organization.

We have a leader of a
very large, important

local organization.

And you’re both
pointing our attention

to population health,
social services.

How do you get that sort
of mobilization and support

and political energy going for
those causes in the same way

that we saw people rising up in
the last 12 months and saying,

don’t take away my
health insurance?

– Yeah, it’s more
difficult, because you

know preventing something
that didn’t happen is tough.

But I think one of the
things we have to do

is we have to do a better
job of grabbing the cases

when something does
happen and point it out.

So Beaumont, Texas, they cannot
turn the spigot and get clean

water.

Well, you know, that’s a
terrible thing from the storm.

But frankly, we haven’t
either made a big deal

and pointed out the fact that
they lost a public health

service.

People have trouble
understanding what

a public health service is.

A public health service is
when you can’t turn the spigot

and you don’t get
clean water, or when

you have something like
what happened in Flint

with the lead in the water.

And we’ve got to do a
better job of making sure

that people understand
that those services come

from good public health work and
a better understanding of what

population health is, and
getting everyone involved.

And the more you build across
sectors, it will be helpful.

One example is that we
know that the business

community, for
example, is trying

to figure out where they
want to put new businesses,

new factories.

And so they’re
beginning to think

about putting those
things in fundamentally

healthy communities, because of
the cost of their health care

to their health care
costs in the companies.

And so they’re looking
for surrogates.

And it turns out one of the
surrogates that they use–

some companies have used–

is the percent of
obesity in the community,

you know, because of all of
the outgoing costs on that.

So the business
community gets it.

We just need to do a
better job of getting

other people to get it.

– I would add that I think this
is a challenging responsibility

for our organization
in terms of thinking

about where do our
responsibilities begin and end.

You know, I use the
example all the time.

Somebody falls in a pothole
on Dorchester Avenue

and breaks their hip.

They come to our emergency room.

We decide they
need an operation.

Not to be graphic, we
take their clothes off.

We put them on a
cold, hard table.

We paralyze them.

We put them to sleep.

We jam a steel rod in their hip.

We wake them up, and
they go upstairs.

They learn how to walk
again, and they go home.

Are we responsible
for the pothole?

And we have to do what I
just described perfectly,

so that person thrives
through that operation.

And I worry that the
health care system

will fall into what I think has
challenged some public schools,

particularly those who serve
low income communities.

Kids weren’t earning
because they were hungry.

We gave them breakfast.

We gave them lunch.

We send them home with backpacks
of food on the weekend.

But no one’s learning math.

So I think that I was
very happy to come here

to think about this from a
standpoint of citizenship,

because I think that those are
questions we have as citizens.

I don’t know what the answer is.

And I love what we do and
I love talking about it,

as was probably obvious.

But I worry about where our
responsibilities begin and end

and how you can’t be all
things to all people, which

is why we have public
health colleagues

and colleagues in
academia and colleagues

in the criminal justice system
and colleagues in housing.

And we’ve got to pull
communities together

to solve these problems.

– I’ll just add that just
as Dr. Benjamin said,

not only do we need to have
a sort of paradigm shift

from treatment to prevention,
but also a paradigm

shift in recognizing the
social determinants of health.

And you do see little
pockets of activity

around environmental justice,
the rise in some pockets

of the citizen scientists.

Unfortunately it’s
oftentimes in response

to something like the
Flint crisis, you know,

like it takes that to get
this kind of mobilization.

But hopefully,
slowly but surely,

we’ll come to see all
these factors that

affect people’s health
and not just treat

people for a condition
after it starts.

– So we’re going to open
it up for questions.

and the way we’re going
to do this is please–

we have a microphone here.

–form a line.

And then do we have
a roving microphone

if there’s anybody who’s not
able to get up to get in line?

I think you can– if you’re
unable to get in line

you can also– raise your
hand and flag somebody.

When you ask you question,
please tell us your name

and if you’re from a
particular organization.

And also make sure
you do ask a question.

Short comments with
a question are fine.

But we’re not looking for
two or three minute speeches.

Thank you.

– OK, great.

My name is Claribel Santiago.

I’m unemployed.

I just wanted to
say that regarding

the advanced study,
the Radcliffe

Institute for Advanced Study–

and Professor Cohen is
a history professor.

Let’s see.

The history of the United
States is capitalism.

And all the presenters
today are hopeful.

And I’m hopeful.

But In other words, we come to
these meetings all the time.

And I think the only
way to mobilize people

so we stop the political risk
is the capitalist paycheck.

And we need to–

again, the way I feel we
need to mobilize people

is wait till there’s a holiday,
Thanksgiving, Christmas,

New Year’s Eve.

Get buses loaded,
and take them over

to the politicians’
suburban home

and ask to use the bathroom.

Ask to use– you know, can I
have a piece of your turkey?

You know, I’m here
because I don’t

have enough funding
for the schools

or the infrastructure
in our cities.

So it’s not really
a question here.

And I just wanted
to make that point.

I don’t know.

I heard that a long time
ago or I read it somewhere.

You know, just get
people’s attention.

Get people on buses and take
them out into the suburbs

and ask the politicians that
are making tons of money.

– Great.

– And I just wanted
to make that point.

– Thank you for your comment.

– Andrea Campbell
brought up a question,

but I’d really like Kate
Walsh to kind of answer it.

In a world in which the
child of a single parent who

makes $6,000 a year,
the child having asthma,

is considered too
rich to get Medicaid,

the level of willingness to
share strikes me as appalling.

And yet there we are.

Those of us who are old
enough to have Medicare,

we’ve got ours.

When I was employed by
an employer, we had ours.

The problem is that it’s
going to other people.

Except Kate Walsh, you represent
the one unifying institution.

– No, no.

[INAUDIBLE]

– Ah yes, rich people
and poor people both

count on that hospital.

When you break your leg
on Dorchester Avenue,

rich and poor–

the richest people
in the area want

to go to Boston City
Hospital emergency room

and get it fixed.

And so [INAUDIBLE],, in
my community in Oregon,

the head of the
regional hospital

said that before the ACA,
they were losing a couple

of million dollars a year.

They were coming to the
donor community to find it.

Now with the ACA,
they’re profitable again.

At least they’re
breaking even again.

Are the hospital
administrators doing anything

to share with politicians
that the Medicaid expansion is

the solution or a solution
to keeping hospitals open?

It strikes me that you
have the great power

to make a difference.

– I think we need to do
more, which is partly

why I talked about the call
to action for our sector

around Medicaid.

But just to come back to
Texas, not that it’s not

fun to bash them, what
they do is they– you know,

they haven’t accepted expansion,
but they have a $15 billion

waiver.

They have a $15 billion waiver.

So a public hospital in
Texas has the ability

to care for low income people.

They just do it through
a disproportionate sharer

hospital methodology.

This gets pretty arcane.

So the kid with asthma
in Texas probably

gets his inhaler in a spacer.

They probably jump
through more hoops.

They’re more apt to be at a
county hospital than they are

at Texas Children’s.

But I think– actually, they’re
probably at Texas Children’s.

I have a friend who’s on the
board of a hospital in Corpus

Christi that’s largely–

it’s called Driscoll.

It’s a children’s
hospital down there.

I think it’s like 70% Medicaid.

And then the rest they do
through supplemental dollars.

So I think our sector has to
embrace the Medicaid program.

And I’m proud to work
at a place that does.

And Oregon is a terrific
state in that way as well.

Do you have anything to had.

– As a researcher, I do
have to just point out

that the studies are pretty
unequivocal that states that

haven’t expanded
Medicaid, even if they do

have other supplemental
safety net programs,

it’s not comparable.

Health insurance is different–

– You’re right.

It’s not.

It’s not comparable.

–than safety net funding.

And the patients experience
a clear difference.

When someone comes
to the emergency room

and needs emergency
treatment, yes, they’re

required by law to receive it.

But it’s all of the cases
short of that emergency

and after the emergency that
without health insurance,

people really struggle to get.

– Yeah.

– If our questioners can–

Dr. Benjamin, did you want you–

– Yeah.

It’s more than just health care.

So for a lot of the
smaller hospitals,

they’re the only hospital
in the community.

I mean, one of the reasons
that the previous bills failed

was that in a lot of
rural communities,

even those places
that didn’t expand

were going to the legislators
and telling them just that.

Also, in many of
those communities,

the hospital is the biggest
or only employer in town.

And so it’s also an
economic development issue

for those communities.

So you know, people
keep forgetting

that this is 18% of our
gross domestic product

and it is a major economic
engine for our nation.

– I have a brief question.

– And please introduce
yourself before your question.

– I’m Horace [INAUDIBLE].

I’m a Harvard Medical
School graduate.

And I spent the first half
of my career practicing

medicine at the Johns
Hopkins Hospital

and the last half in big pharma.

I work for Pfizer now.

My question is this.

I’m surprised that in
all these lovely talks

one thing I haven’t heard about,
which was always my diagnosis,

was that part of the reason
we’re in the fix we’re in

is because there
are too many people

making too much money
off the present system.

Is that my naivete
or is that important?

[APPLAUSE]

– Well, I’d never go
after anyone’s income

other than to say that there
is a maldistribution in terms

of the work, in
terms of the value.

And of course, one
thing to fix that

is to begin looking at value.

And you know, if
we did it right,

that would mean that primary
care practitioners would

make a whole lot more
money than they do today.

– Hi, my name is
Frank Singleton.

I’m a retired health officer.

I’ve worked in four states,
the last 15 years in Lowell,

Massachusetts, where we had
30 school nurses, for example,

because of the medical needs
of the population in the school

system.

And I hope that we can now
bill the Affordable Care

Act for their services, to just
help strengthen that program.

But the point I want to make
is you’re seeing an iceberg

and you’re talking about
what’s visible on this panel.

If you look at the money, I
was the city’s ADA coordinator,

for example, Americans
with Disabilities Act.

Between the disability
community and long-term care,

you’re seeing almost
half the money

in this pot of money
being spent in that area.

You may want to actually have
a separate panel sometime

in the future about that.

Because I think Congress
didn’t understand that.

Medicaid to them
was poor people.

They ought to be working.

I’m looking at
the issues of, how

do you keep people
in the community

without having support
services or they become

institutionalized to disability.

A lot of the chronic care
people fall into that category

as well.

But with support and
health insurance, they can.

So I’m really looking
at can, we discuss–

one of the biggest
issues here is

I think the fact that we are
not just talking wellness.

We’re talking what
happens when you

start going into
you needing care,

and especially when you
look at long-term care.

Right now, long-term
care is in grave danger

of going bankrupt because of
the reimbursement structure.

And I had to deal with 15
nursing homes on Lowell.

And there are real problems
that need to be addressed.

And I don’t see that
being discussed.

Most of this revolves
around the exchanges

and what goes on with that
part of the program, which

is important.

But I don’t see much discussion
on the disability portion

and the long-term care portion.

– I’ll say that for political
scientists who study health

policy, the lack of political
mobilization around long-term

care issues is one of
our central puzzles.

And we have a few
ideas about why

you don’t see more activity.

I mean, one is that we’re
a youth-oriented culture

and there’s just not a
lot of public discussion

about disability and senescence,
both culturally, societal,

and within families.

I have an 82-year-old mother
and a 70-year-old mother-in-law.

And it’s really tough to talk
to them about these issues.

So that’s one issue.

It’s also a prime example
of market failure.

Private long-term care insurance
is a terrible market failure.

And so really people are just
left with family resources.

And you think about who could
be the potential constituency

there.

Well, there are the
adult caretakers.

But obviously the
caretaking episode

itself is all-consuming
and exhausting.

If you’re caretaking
for an elder,

it ends in that person’s
death typically.

And that’s not a
moment where you’re

going to embrace
political mobilization.

Also, there’s something
about Medicaid

which is in some way I
consider the sort of tyranny

of a half solution, which
is that policymakers know

that long-term care
is very expensive

and they don’t want to take it
on more than they already are.

And they just turn to
Medicaid and say, well, we

don’t need to do anything
else about long-term care

because we have Medicaid,
end of conversation.

And so it’s a puzzle why we
don’t have more mobilization.

That’s something–
it actually would

be a great forum for Radcliffe
to take up because it’s

a huge issue in our society.

– Yeah, let me just add that
it was a great shock to many

members of Congress that
Medicaid covered long-term

care.

– Yeah.

– They had no clue.

– Yeah.

– Now, we can talk about
how people got to Congress

and what their background
experiences were

before they got there.

– Radio talk show host.

– But the enormous lack
of regular order when

we had committee hearings
and had discussions and had

debate and things became
public was astounding.

They were not prepared
for some of the protests

and for the nice
lady in the front

here who talked about
citizen activism.

What happen this time that
didn’t happen after the ACA was

originally passed and
the Tea Party revolted

was that citizens
did not give up.

They were arresting
people in wheelchairs,

dragging them out
of wheelchairs,

dragging them across the hall to
arrest them, all on television.

And these were people who
were certainly disable,

but they were skilled
at protesting.

They had been trained
not to resist,

in nonviolent resistance
and proper advocacy.

So you know, we had lots of
pictures of disabled people,

frankly, being
abused and not people

who were disabled
being the abusers.

And I got to tell you that
that was, from an advocacy

perspective, helpful.

– The Affordable Care Act debate
did include some features that

I think got a little
bit less visibility–

and our panel’s comments
probably reflected that–

that did apply to care for
people with disabilities

and in long-term care.

One of the populations
that we know

is most in need of
improved care and policies

are those people dually enrolled
in Medicare and Medicaid.

And this is a group
that has really never

had a dedicated policy focus
until the Affordable Care

Act created a new center
for dual eligibles,

to try to improve
that coordination.

And then we also have
seen a lot of states–

well, federal
policymakers may not know,

but any state policymaker who
looks at the Medicaid budget

knows that long-term
care and care

of people with disabilities is a
huge portion of Medicaid costs.

Now, the approaches
that then you

see state policymakers proposing
varies quite a bit from, let’s

provide more social supports
and all-inclusive care

and try to improve
care coordination to,

let’s find some private
insurance plans that

have no experience caring
for this population

and see if we can
contract them out there,

and that might save us money.

So there’s a range of values.

But it was a great
question and I’m

glad that the panel got to
comment a little bit on it.

– OK, my name is
Katherine Morrison,

and I’m a member of APHA.

So hi there.

A quick question– there appears
to be– and Dr. Benjamin,

you just actually
touched on it–

a lot of ignorance when it comes
to the importance of Medicaid

among the legislator.

So I’m wondering if
anything is being

done to try to actually
provide more education to those

who make our laws and policies.

And that includes Trump.

– Yeah, certainly
there are many groups

that are going in and
talking to many legislators.

And in defense of some of those
legislators that didn’t know,

the fact that again, you
don’t have regular order, that

meant a lot of things were being
discussed out of committee.

So you had a lot of
people that weren’t

on the health committees
that ultimately had to vote.

And by the way, their
staffs didn’t know either.

Because again, when these
things go through the process,

staffs become educated,
the legislator

becomes much better
educated, and they

don’t get surprised, frankly.

And so yeah, there are
lots of efforts to do that.

The biggest concern
that I have of course

is the current
Secretary of Health,

who has a perspective on
the Affordable Care Act

which is best to say, and kind
for him to say, is old school,

and doesn’t believe in–

he believes in
quantity over quality

in terms of payment mechanisms.

I’m sure he believes in quality.

I don’t want to disparage
him his critical skills.

But the Affordable Care Act,
in terms of its intention

got it right.

But they’re doing
everything they

can to undermine
regulations, under the guise

of upsetting the
patient-physician relationship.

And you know, I think both
his diagnosis is wrong,

his therapy is wrong,
and everything he’s doing

is wrong on that.

But you know, we will continue
to try to move that agenda.

– Do you want to say
anything on this?

You know, one thing I will say
is that I know that there are–

I see some of my colleagues
here who also do research.

The last six to nine months have
been an interesting challenge

for academic researchers in this
area, which is how far are you

willing to go to put out your
perspective and share evidence

and try to influence how
policymakers are thinking

about these issues when
some of the very basic facts

are either unknown
to policymakers

or they intentionally
mislead about?

And I think it has been an
eye-opening experience, and not

just in health.

We know we see this going
on in environmental health.

We see this in sociology, legal
studies, immigration policy,

this doubt of science,
and the need in academia

to step outside of our
comfort zone and say,

here’s what we do
know and here’s

what we don’t, here are
the areas of uncertainty,

here are facts,
here are studies.

And on the Affordable
Care Act, I’d

like to think that
some of that sunk in.

The story I sometimes
tell when my students say,

does any of this matter,
the work we’re doing–

you know, my son’s six.

He brings home art
project after art project.

And my favorites are the
sprinkle, the glitter projects,

right?

You put all this glue on there.

You decorate it up.

You pour all the glitter on.

You pick it up and you
shake it, and 90% of it

falls in the ground.

I hope a little bit of
our research sticks.

And that’s my goal.

– Hi.

Thank you for
sitting on the panel

and sharing your
knowledge with us today.

I’m Victoria.

I’m a graduate student at the
Heller School at Brandeis.

My question is
more hypothetical.

And it’s mainly
directed at Kate Walsh,

but anyone else can respond.

I love your optimism about
the holistic approach

that hospitals are taking.

But I’m kind of
curious on how you

think institutional
citizenship would be impacted

by a single-payer system similar
to what Bernie Sanders just

proposed in terms of
or under the assumption

that hospitals would lose money
due to reimbursement rates

and restrictions on
private insurance,

if you think it would
move that forward in terms

of an incentive to hit earlier,
or if it would kind of move it

back and regress to follow
the money and save on costs.

– So that’s a really
good question.

I think we’re in
a unique position.

I think I said at the outset,
but maybe too quickly,

that we’re about
79% government paid.

So for us, that’s
more theoretical.

We’re already kind of there.

We’re a single-payer with
two different flavors

between Medicaid and MassHealth.

I think a single-payer could
be disruptive to our system.

We were just talking
about that, whether you

need to kind of install
it or evolve towards it.

And I worry about it being
a stalking horse for people

who point to that to use it as
a reason to upend the Affordable

Care Act.

I think we did a lot of work.

This is really
complicated stuff.

And we really could
make your hair hurt

if we started talking about
all the details behind it,

particularly this end of
the table, or these guys.

But I think the–

so I worry about it
being a stalking horse.

I think you see it a
little bit differently.

– Yeah.

So first of all, I’m excited
to hear the next panel.

Because we don’t know
what single-payer means.

– Yeah

– OK?

We know that we’ve seen
Senator Sanders bill.

I’m very excited about it and
by what he’s thinking about.

And I like the
construction on how

he’s talking about implementing
it over four years.

Of course, you saw implementing
ACA over multiple years

did for us.

So I think there
are real challenges.

And I think the question is
still, how do you pay for it?

And you know, my organization is
strongly long-term single-payer

on the policy.

The question has always
been, how do you get there?

How do you evolve to it?

One way may be to do Medicare
for all adults and Medicaid

for all children first
as an interim step,

and then figure out how
you harmonize the two.

So I suspect whatever
happens, there

will be some harmonization
process, assuming we get there.

– All right, we have
time for one or maybe

two more questions.

– I’ll be fast then.

I’m Debra Straud.

I spent my first half of m y
career in technology transfer

and the second half in
behavioral health policy.

And I’m wondering if you
could talk a little bit more

about workforce development
and specific challenges

in recruitment and retention
and compensation and the skills

that it takes to form this
kind of holistic collaboration

to care for communities.

– Do you want to start first?

– That’s a great question.

I wish I knew the answer.

I think we’ve got
a lot of work to do

as we move from making sure when
people roll in the emergency

room or come to the clinic
we can take really good care

of them, but finding patients
where they live and finding out

what’s important to them.

You know, health
care in America is

very good at asking,
what’s the matter?

We’re less good at asking,
what matters to you?

So training a workforce
that can do that is–

you know, you think
about end-of-life issues,

think about community
health and wellness.

We’ve got some work to do.

I would not purport
to be an expert.

You maybe [INAUDIBLE]–

– Yeah.

The medical schools at least are
beginning to teach and move us

from a training program
where we taught people

to be independent, on their
own, and know everything,

to working in teams and
relying on others in terms

of being part of a team.

And in addition,
there is much more

work on the social
determinants happening

within schools of medicine.

Schools of nursing have
always taught teamwork.

And the challenge of course
is recognizing, allowing

nurses to practice at
their full potential,

and other practitioners,
you know–

– [INAUDIBLE]

– –pharmacists, PAs,
[INAUDIBLE] all those folks

so we can build that.

And we do need to begin doing
a better enumeration about what

our workforce is going to be.

And the thing that’s
going to drive us there

is all of us baby boomers
getting old and recognizing we

don’t have the workforce trained
in any way to take care of us.

– [INAUDIBLE].

– We’re going to move us
onto our very last question.

And then we’re going to
adjourn before the next panel.

– Hi.

Thank you for being here.

My name is [? Dayelle ?] Smith,
and I work as a consultant–

Hi, Kate– to hospitals
and health care insurers.

And I’ve worked for insurers
and even for Medicaid

and do that stuff
that makes your hair

hurt with the numbers.

But my question is–

so here– and my avocation
now since the election

has been the resistance,
advocacy, political activism,

new to me.

And I guess what I’m saying
is, here we in a situation

where they were dragging
disabled people out

of the congressional offices.

And yet it still took John
McCain’s one last vote

to defeat the last proposal.

And I guess what I
want to know is–

we’ve protested.

We’ve been in the streets.

We’ve marched.

We’ve called.

We’ve faxed.

We did everything we could.

We’re so close.

What are your
organizations going

to be able to do with your
power, your voice, your money,

to stop this horrible events?

And you know, will you
get more political?

Will you work on
the next elections?

Will you become more partisan?

What is your role?

– Great.

– How do you see your role–

– Thank you.

– –in changing the future?

– I’m going to direct this
to our political scientist

for the last word, just
given time constraints.

Because I know that probably
Ms. Walsh and Dr. Benjamin

could talk about this
for a good hour or so.

– All right.

Yeah, well, you
know, I think we need

to keep working on
mobilization of everybody.

And you know, organizations
have a tough time because you

can’t be too political.

But we have to get the
voice of everyone out.

Because we have one party–

I won’t say which one,
but you can probably

figure it out– that’s not
so interested in governing.

And we need to make sure
that everybody, especially

those in need, are voting.

So the resistance needs to
continue, even against the more

sly and hidden ways that these
programs are being undermined.

– Well, thanks so
much to our panel.

And thank you for
your great questions.