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1804 Massachusetts's 12th congressional district special election

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A special election was held in Massachusetts's 12th congressional district on September 17, 1804 to fill a vacancy left by the resignation of Thomson J. Skinner (DR) on August 10, 1804[1]

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  • ✪ It Depends What State You’re In: Policies and Politics of the US Health Care System | Part 2
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- Welcome back, everybody. I hope you had as interesting a conversation in your break as I did at mine. And we brought up a bunch of problems in the first half. And it's up to this panel to bring us all the solutions. My name is Janet Rich-Edwards. I'm the Life Sciences Director here at Radcliffe. And it's my pleasure to introduce Zirui Song, who's going to be our moderator. Zirui is an Assistant Professor of Healthcare Policy at Harvard Medical School, and also an internal medicine physician at MGH. He has worked in the US Department of Health and Human Services, the Center for Social and Economic Dynamics at the Brookings Institution, and the Massachusetts Health Policy Commission. And you can read his many awards in your booklet if you like. He is very able to lead this panel on alternative models at state and federal levels. Thanks. - Thank you so much for that kind introduction. Good afternoon, everybody. Thank you all for being here. Thank you for coming back. It's an honor for me to be a part of this distinguished panel among all of the guests that you will hear from shortly. My role is to facilitate the discussion and help bring about as many insights as possible for you all to consume. In framing this discussion, we can think about alternative models to healthcare reform on a spectrum, if you will. On one end, there is the single payer types of policies. Again, single payer may mean many different things. And I hope we go into that today. It involves decisions like, who's bearing the risk, how do we pool the risk, how do finance the care, how do we pay for it, would you have a fee for service system under single payer, would you have a global payment system under single payer? Those are some of the nuanced decisions under the single payer end of the spectrum. On the other end of the spectrum, we have decisions surrounding things like, how far do we allow, or how much do we allow private insurance companies to help bear the risk at the expense partially of government? Decisions such as, how far do we expand a program like Medicare Advantage, or a program like the exchanges, which operate based on a private platform? Within this spectrum, and in thinking about the alternative, I would like to pose and encourage you to think about three fundamental questions. The first is to what degree is guaranteed coverage required to achieve universal coverage? I'd encourage us to think about the nuances and the differences between guaranteed coverage and universal coverage. The second is to what extent does health insurance provide health security? Again here, the nuanced differences between having health insurance and actually having health security. The third question is how do we align affordable healthcare with acceptable healthcare? Again, the nuanced differences between what is affordable and what is to us, as a society, acceptable. Now, in thinking about these three questions, I'd simply like to pose that there is a positive way of thinking about it. Positive not from the good or bad perspective, but positive from the positive or normative perspective. So to each of these questions we can think of it from a policy standpoint that is positive and from a policy standpoint that is normative. For the first question of the differences between guaranteed coverage and universal coverage, rephrased as what is our path to universality, the positive interpretation might be that this is about a set of regulations or requirements. So what regulation or requirement would you like, would one vote for? But I would argue that the normative stance, the normative argument, behind this is what is the role of government in our society? I hope our speakers touch on that today. For the second question, to what extent does health insurance provide health security, the positive interpretation might be that this is about actuarial value, that when you have an insurance plan it's got to cover a set of things. And how broad is that set of things under the universe of everything that medicine can provide? But the normative side of this is much more about what is the definition of security in a person's life. That's a different question than the positive interpretation. And the third overall question, how do we align affordable healthcare with acceptable healthcare, affordable from a positive standpoint might center on cost sharing. What is a person's premium? What is a person's deductible? What is a person's co-insurance or co-pay at the office? But from a normative standpoint, the differences between what's acceptable and what is affordable may center, at the end of the day, on what is right. What is right. I will close my remarks there and introduce you to the first of our speakers, who is Mr. Michael Lighty, the Director of Public Policy at the California Nurses Association and the National Nurses United. Following Mr. Lighty will be Professor Bill Hsiao, who is an Endowed Professor of Economics at the Harvard School of Public Health. Following Professor Hsiao we will have Dr. Michelle Doty, who is the Vice President of Survey Research and Evaluation at the Commonwealth Fund. Thank you again for being here. I look forward to learning with you. - Thank you, Zirui. And thank you all for being here. I don't know how I got on a panel with all these doctors-- that's the question-- and in this conference. So I really appreciate the Radcliffe Institute including us. My talk is really about SB 562, but I have to start with politics because I took that out of this talk. I was at Senator Sanders' announcement of his Medicare For All bill on Wednesday. And I've been doing this work since 1991. And I can tell you it's a different reality for healthcare policy and politics in this country. There is-- I mean, to go essentially from zero to 17 senators from 2013 to 2017, to see the upsurge, and how the Senator made that a centerpiece of his presidential campaign and since then. And then, to see the polling, which as we know, varies tremendously by what type of question you ask-- how you ask it, you can generate-- you can generate 80% support for Medicare For All and you can generate 30% support for single payer. But overall, the trend is clear. It's clearly on the upsurge in popularity, clearly on the upsurge as a political-- as Professor Carpenter said-- a political litmus test. So we are in a new moment politically. And our approach in California reflects that moment in the sense that we believe you have to start at the state level because federalism, as our other colleague talked about, is at the heart of the American system. And the example of Canada is instructive. It started in Saskatchewan and became Canadian Medicare. And so, we do believe that if we can prove that this type of program works in a state like California, especially which has the resources of a nation, then we can do it federally. And so, that is actually part of our political strategy. Rooted in this is-- to start to answer your questions-- we really are on the side of guaranteed healthcare. And we're on the side of that as both a frame and as a policy position. We see it as a moral imperative because really what I'm talking about is the nurses perspective. I'm going to provide an analysis of single payer that reflects two things. One is what nurses bring to this issue in their perspective of rank and file nurses at the bedside. And also, in relation to the Affordable Care Act. So we did two things. We took a lot of policy work that our union had done over a number of years. And we took the New York Health Act, which was passed by the New York Assembly, and really was the first state single payer bill to be designed after the Affordable Care Act. And so, that's the policy environment. But we do start with these citizenship values. And that's why I was particularly excited to be here because we really believe that a healthcare system has to reflect those civic values that animate our society. And so, we talk about equality, justice, and democracy. A single standard of care for all is at the heart of this. A single standard of safe therapeutic care is how we put it, a universal standard of excellence. One illustration of that. I talked to the director of a trauma center at a major medical center in Southern California. He said yeah, not only do we spend $80,000 a month trying to get paid from the insurers, but we also have different standards and levels of care based on what plan you have. Not simply different benefits, not simply different coverage, but literally a different standard of care derived from this fragmented system. So we start with that. But we start with that the right to health. Not simply the right to healthcare, but the right to health, as Dr. Benjamin was talking about earlier. That is a core value of justice that we have to apply to the healthcare system. Otherwise, we literally cannot end the disparities that still characterize it. And finally, one of the key points about a publicly financed system, like single payer, is that it is more democratic. We are bringing the civic value of democracy and popular participation into the healthcare system because we're going to finance it publicly through taxes. And that value of participation and control and democratizing that system is at the core of what we're trying to do. When we do look at the surveys-- this is from the Kaiser Family Foundation-- what people care about, generally, they think quality of healthcare is good. But if you look at their premiums, the deductibles, the drug costs, whether their insurance is going to cover the services they need, whether they can go to the hospital without paying more, what you realize is finances are a barrier to the guarantee of healthcare. That's the barrier we're trying to overcome. The insecurity derives from that, the restrictions on access, based primarily in finances, but also in narrow networks. And some of the changes that have been made on the delivery side have definitely gotten people concerned. What they don't believe is that they use too much healthcare. And while we are explicitly building on the foundation of the Affordable Care Act, we do reject the fundamental premise of it. And that is that, as an earlier presentation said, it was designed to bend the cost curve. That was the-- that was the mantra coming out of the Office of Management and Budget during the Obama administration. And the way to bend the cost curve is to put skin in the game. So you had to pay more in order to use-- in order to properly utilize healthcare. And what we're going to see instead, of course, is that Americans have-- go to the doctor less, they stay in the hospitals for shorter lengths of stay. And in fact, it is not a question of overutilization, but primarily an issue of cost derived from the price of healthcare. None of the concerns that Americans have can be addressed by transparency. There was a lot of discussion, particularly in 2016, about, hey, if we just open up and we show people what things cost, or we tell-- for example, a bill just passed in California on prescription drug transparency. We don't believe that any of that is going to make a difference. It's really not whether they know. It's about whether they get the care they need. That is really, I think, at their top concern. So what our perspective is is that the healthcare system is primarily organized as an industry. And that industry-- and Elizabeth Rosenthal, a longtime reporter at the New York Times has written a book called American Sickness. This is her premise. That really what we've seen, in her lifetime, as a writer is the transformation from a care giving profession to a healthcare industry based on revenue and profit. And it is that model that is driving the cost increases. And we have to change it. Quality is actually skewed to the top. During the Great Recession, for the first time, wealthy people spent more on healthcare than your average income person because they simply had the resources to do it. There are a couple of analyzes about that. Angus Deaton, 2015 Nobel Prize winning economist, has said that healthcare is a driver of inequality, not simply a reflection of it. But how it's financed, how it's accessed, where the resources go, drives inequality in the society as a whole. Technology improvements benefit the wealthy most and other things that are capital intensive. Obviously, expensive prescription drugs is a good example as well. So when we look at this we compare-- this slide's a little skewed, but I'll explain it. We're essentially looking at the contrast between maximizing revenue or this single standard of care. Because to maximize revenue, of course, means you've got to cherry pick the patient population that you insure. Because if you insure a lot of sick people, you're going to need those reinsurance payments that apparently Tom Price doesn't want to give the insurance companies. So you can't have a single standard of care because you've got to attract those ultimately who don't need very much care. Market competition is not effective because essentially what we have is we have the hospital corporations, in many cases, dominant players in their local communities, prescription drug corporations, and the insurance industry. None of those entities have any regulation on price. They literally can charge whatever they want. There is no price regulation at any point in the system. So the market competition actually benefits them as it benefits their revenue. A higher prescription drug can justify a higher premium. Higher hospital charges can justify a higher premium. Similarly, the higher premiums provide more revenue to the prescription drug companies and the hospitals. What really is at work here is that industry dynamic. That's opposed to a safe, therapeutic care in the most appropriate setting because you wouldn't bring those market values to bear in the clinical setting. There is a great emphasis on shift to lower cost setting. Here, we have an example of where a lot of the emphasis in the healthcare system is to go to outpatient care. That is, of course, in many ways beneficial. If it's driven by budget and cost, then it's not. So if a procedure that's more safely done in the hospital is instead done at an outpatient clinic, the difference in revenue to an entity like Kaiser can be $0.80 on the dollar. The same procedure in the hospital can cost that much less in a clinic. And in many times, that's beneficial. In other times, is it a question of is the clinical efficacy the driver there? We believe in the highest skilled caregiver closest to the patient. That's directly counter to workforce models that would say, no, we need to de-skill and have less expensive healthcare workers as part of the industry model. Hospitals, in many cases, are becoming technology centers with a lot of the care being delivered elsewhere, maybe through even telemedicine. Rather, we want to use technology to enhance professional clinical judgment. And so, we contrast this ultimately with a healthcare system to meet patient needs based on the morality of caregiving. And that is what informs our perspective on SB 562. The morality of caregiving has to be at the heart of our health care system. So we favor social insurance in that we want to replace these rising premiums with progressive financing. I never talk about public financing of health care without saying that it will replace insurance company premiums, deductibles, and co-pays. That's at the heart of it. It's not an additional amount spent. It is a replacement for what we're currently spending and then generating savings. No cost to access care where you need it. We eliminate deductibles and co-pays. Your average deductible now is $1,400. We identified 36% of Californians, 15 million Californians, have a deductible of $2,000 or more. The research shows concretely that that is a barrier to access. Comprehensive benefits not based on premium costs because we have to separate what you pay for healthcare from the healthcare you need. And that's a core value of single payer financing. Complete choice of a provider. That is a bias that we have. We believe narrow networks are counterproductive to insuring guaranteed healthcare. And we also don't believe that industry practices, like mergers and acquisitions, add any value to the system. It's a public solution. Everybody in, nobody out, automatic enrollment, perhaps there's some level of state-based administration. There is a role for supplemental benefit programs, but you'll see in 562 it's a very comprehensive one. And ultimately, the key point, costs lowered through leverage to control prices, progressive financing, and universal healthcare. And that includes mechanisms like paying for value over volume through global budgets on hospitals or other per capita payments. And so, in that sense, it builds upon the Affordable Care Act, but we do believe that prices are the driver. Progressive taxation, again, price controls on drugs and devices, elimination of profits, marketing costs, and waste, global budgets, as I said, and then, negotiated fees and payments to providers. So essentially, what we do is we create a single risk pool with everybody in. We look for uniform rates, so that all providers are paid on the same basis. And then, we use some of the mechanisms that I learned from Professor Hsiao to create a single pipe, which is the payer, to providers. That's the essence of the proposal. And it's like Medicare. It's an expansion-- at the federal level, it would be an expansion of Medicare. There are various types of single payer. We could discuss more in detail the different national systems, as I know Michelle Doty will do far better than I could. And obviously, the VA is a good example of how controlling prescription drug prices and actually an effective use of electronic medical records could be emulated. Quick look at healthcare spending. And you'll see there's a lot of discussion about out-of-pocket expenses. And you say, well, you're going to eliminate deductibles and co-pays, so how are you going to regulate access or appropriate utilization? Other countries have out-of-pocket costs. Well, it turns out those out-of-pocket costs, generally, in many cases, are quite low. And it's not, in fact, a comparable situation. In Switzerland, the system that's most like ours, has actually higher out-of-pocket costs than us. Otherwise, the national systems have substantially lower. We essentially spend more and get less in other countries. This is a table on outcomes. What I like about this-- status rather, demographic status and health outcomes, risk factors. What I like about this is that it shows that a lot of those notions that we believe are drivers of healthcare costs-- obesity, of course, we're way up there and it is a big driver-- are actually less prominent here. We have a society that isn't the oldest in the world, in fact, on average, as a percentage of population. That's not necessarily a driver of healthcare costs. I'm going to skip over this. We do have, as I mentioned, fewer hospital-- shorter length of stays and fewer doctor visits. This is why does healthcare cost so much. Because prices are high. It sounds like a joke, but it's true. You can see a comparison of prices just on some procedures, pretty radical differences. The favorite one is an appendectomy in the United States is going to cost three times what some countries charge. And so, you see here, there are pretty substantial price differences in the US driven by this industry model. Prescription drug prices are another good example. This is a chart that shows employers are paying more in compensation, but wages aren't going up. It's essentially a transfer of wealth between corporations-- from corporations to healthcare insurance companies. And the workers are ended up paying most of it. I see I've gone on and on about the politics, so I'm not getting my presentation done on time. But essentially-- I want to just do this quickly. The healthcare disparities is exactly as you said, Dr. Benjamin, completely related to zip code. These are comparisons of different geographic areas in California. Essentially, your life expectancy depends on where you live and your race and class. And that's just the way it is. And so, we have to address that. Three million Californians still under-insured. Half of those are undocumented. Talking about the ACA. I just want to get quickly-- I got to get out of here. This is what we're trying to do, as I say, pass legislation in California. And then, let that be a model to federal Medicare For All and win healthcare justice. Just quickly on the key provisions of the-- and then I will get out of here. So I apologize. The key provisions-- we call it the Healthy California Act. This is the definitions. It guarantees healthcare to all residents of California. It eliminates insurance company bureaucracy, claims denial, and marketing costs. It really emphasizes that everybody is in one system, so you cannot have private payers paying for those benefits that the system covers. So that provider is either going to be in the system accepting payments from it, or they're going to practice entirely outside the system. Insurance products can only cover those benefits that are not covered as part of the system. And then, it's this independent healthcare authority, the single pipe, that channels existing federal and state healthcare revenues. So it depends upon getting those waivers from the federal government to be a part B provider under Medicare, to take the Medicaid money that's coming into the state, and to get the money that is currently spent as tax credits into the system as part of the public financing. For example, $53 billion is given from the federal government to California employers as a tax benefit for providing insurance. Our view is those insurance markets don't exist without that tax subsidy. So instead of having that subsidy go to the profits of the insurers, it goes to pay for healthcare, as an example. We do provide complete provider choice. And we also-- and this is, I think, a key point-- our bias is on professional clinical judgment. We believe that has to be the basis for healthcare decision making. And if clinicians are provided with the time and resources to make those decisions, and we create a system where you can evaluate those decisions after the fact through quality review, catch outliers, that is a much more effective way than pre-authorization, than claims denials, independent medical review by insurers. And nurses will tell you that insurance companies are making clinical decisions every day. And that is what we want to seek to eliminate. Here are the benefits. You can see, on the long-term care piece, we are going to continue the existing Medicaid benefits, but not means test them. So that's an expansion of long-term care. We are not yet tackling nursing homes. That's projected to occur within the first two years. We did an economic analysis. We estimated $331 billion, saving California $375 billion. Key point, 70% of healthcare expenses in California are publicly financed. We are simply not getting our money's worth. To talk about this-- this is essentially a system that uses tax money to subsidize an industry model of revenue and profit instead of guaranteeing healthcare for all. That's what we're changing. And that is at the heart of it. It's We have a couple of ideas for revenue sources, but it is a substantial savings to business, in particular. 22% for those businesses who are providing benefits now, up to 13.4% for medium sized businesses. It is a way to create jobs and fund innovation and investment. This is our program to win. And I would say, to the earlier question about advocacy, advocacy has put this on the map. Advocacy is driving this in California. We are literally going to have town halls and door knocking in every assembly district in California. We believe that's what it's going to take. So we have to meld-- and it's really nurses in the forefront. So we meld the credibility that nurses bring to this issue, their direct experience with patient care and the insurance companies, and a approach to this that emphasizes clinical judgment as we put everybody in one risk pool and eliminate the fragmentation of the system that is responsible for so much inefficiency. So I look forward to talking with you more about it and really appreciate the opportunity. Thank you very much. - Good afternoon. I'm an economist, if you read the introduction. And you may wonder what would the economist know about healthcare. I don't know anybody want to voluntarily give me a definition, what is a male economist? Let me offer one to you. A male economist is one with 1,000 theories about how to make love, but have never met a girl. And I want to say that I did meet a few girls on single payer. In my professional work, I designed a single payer system for nine countries around the world. Half of those countries did adopt them. The one with the longest history is Taiwan. So I'm-- And then, when the state of Vermont commissioned my team, designed one for Vermont. But then, it did not get implemented. So I come here to give you a presentation to actually talking about something that Professor Campbell and Carpenter will be better to talk about. And that is the political economy of a single payer. And so you have a better-- perhaps, you can get a better appreciation the difficulty to climb that mountain. And then, what citizens can do to actually move up that mountain. So with that in mind then, let me just quickly-- I will not take up your time to summarize the major problems confronting United States. Even after Obamacare, there are 29 million-- and the latest figure says maybe 28 million-- Americans still uninsured. And there are 30 million Americans are underinsured. At the same time, our costs continue to escalate taking a larger and larger share of the government's budget, Massachusetts budget, your individual budget, employers budget, including Harvard University's budget, and also pay directly out of our pocket, perhaps. And third, if you look at closely, United States have the best quality of care in the world. At the same time, you go to Mississippi Delta, you go to Idaho, you see the third world class medicine there being practiced. It's highly uneven in America. As well we do not really emphasize prevention and primary care. We have a system, it's hospital centered. So this is where we are. How do you solve that problem? Well, I like to ask why. So I'd like to leave a point with you. I like to argue the reason is America is the only affluent country in the world build this system on the free market principle. No other affluent country does that. If you have free market, you want to give people free choice of insurance, doctors. You want to give doctors, hospital free choice to charge patients. You want to give freedom to have drug companies charge whatever they wish, but protected by patents. That's what we have. So American people have to understand you have to change your ideological foundation upon which our healthcare system is built since 1920s. So here, I like to summarize for you the consequences of what we have then. And that is we have very high administrative costs. Everyone knows that. And that's been documented. FBI declares that there are 8% to 10% of fraud and abuse in claims in the Medicare program, but we are unable to weed it out. I tell you what happened when Taiwan adopted single payer. In the second year, they were able to reduce the healthcare costs by 10% because now they have a complete record of what the hospital and the doctor have done. And they are able to identify who is really abusing the system. And that's what Canada did too on they're single payer system. I don't need to go through each one for you. But high drug costs has been mentioned. And if you look at America, the free market system, our specialists are paid much more than our primary care doctors and our internists. If you look at the data, the average net income of the doctors in private practice, the specialist surgeons are making three times of what family physicians making, or general internists. No other country does that. And what that does is we attract our young medical students going into these specialties. And as the old saying goes, if you teach someone only to know how to use a hammer, everything becomes a nail. And you look at the research report, how many how much over surgery, over performance we have in America. Because 60% of our doctors are specialists. Only 40% are general practitioners or family doctors. And if you look at the UK, Canada, Germany, France, it's just the reverse, 60% primary care doctors, 40% specialists. This is what a market system does for you. So we know these are the problems created by the market through research. Then, I would argue, single payer is only one solution. Because I do not-- I confess, in spite of what happened on Wednesday, I don't think majority America will vote to have single payer system tomorrow. It's a long journey yet. So let's look at what will we save in a reasonably pure single payer system. Here, I can quantify for you through my own research. We can decrease the administrative spending by about 15% of the total healthcare costs, which will come to $500 billion every year. That's how much we're spending wastefully not to do medical care, but to actually make doctors-- like Dr. Torquin was talking to me over lunchtime-- about filling in forms and using different electronic health records. Second is we can reduce the abuse and fraud. That could amount to $150 to $180 billion. Purchasing drugs by negotiating with pharmaceutical companies could again produce close to $150 billion. These figures do not come from me. Come from researchers. If you add them up on the left hand column, they could amount to $850 billion every year savings. Today, among the experts, particularly the economists and policy people, we are public saying in America, every year, we are wasting $1 trillion in healthcare. And I will quote my younger colleague, Dave Cullen, who just gave a talk like that just a week ago. And Dave is a conservative and careful researcher. He doesn't mouthing numbers loosely. $1 trillion every year, that's what we could say. We're not spending that now for effective healthcare for the people. But then, you have to spend money to accomplish single payer. You have to cover the uninsured. That costs money. You have to bring up the people who are underinsured to a standard you're going to give them. You have to provide money, perhaps, to elevate some of the compensation for some specialties, like family physicians or geriatrics. You may have to provide money for retraining of the workers. If you take the difference between the two, you can save close to $500 billion every year in America. So if you want to understand where Senator Sanders come up with a figure he can save $6 trillion in 10 years, it's from analysis like this. It's not pulling out of the thin air. Now, why aren't we there? Well, here I venture into political economy. And Professor Campbell and Carpenter can freely criticize me. I only look at who are the gainers. The uninsured and underinsured, Professor Campbell already talked about low income people and minority people, particularly legal immigrants, they do not participate politically. Although they will benefit, they may not organize and really put pressure to trying to produce benefits for themselves. All Americans, like what Michael just showed in California, could benefit. But the benefit is relatively little, relatively small, let's say $1,000 each person. That's spread to everyone. There is empirical evidence supporting a political theory called collective action. When benefits are spread out to everyone in these modest amounts, people do not organize to support it. That's in well-written books, in textbooks. That's who will gain. Let's say who are going to lose. Private insurance industry, the benefit they get is concentrated. Their annual revenue right now is $1.4 trillion. And their profit, publicly acknowledged, is about 5%. As a actuary, before I became an economist, I can tell you there are different ways to hide your profit in the insurance company's financial statements. And that was my job before I was reborn. You have-- you have to then also-- how about the people who are doing administrative billing and insurance work now. I estimate-- and this is a very approximate estimate-- two to four million American workers may lose their jobs. When you deny people jobs, you know what they will do. They will go in the street and block all the traffic. No one talk about it. Will you take it lightly? Pharmaceutical industry going to be affected. I'm over time now. And I'm going to cut it short. So you look at the winners and losers, then you can say, well, what actions are they going to take? What the losers may do to block you in our political system? I give you an estimate. If the health insurance industry used 1/10 of 1% of their annual revenue to decide to fight you, they can generate $14 billion. Running for the President of the United States only costs $1 billion. And there are eight, nine key committees handle health legislation in Congress. And they only have to be able to determine the election of the chairperson and the ranking member of these committees, 18 people. They can block your legislation or dilute it. That's the reality, people. So where-- so here I'd like to leave you with a cartoon and just to remind you this might be the mountain, or this might be the surgery you have to perform to achieve single payer. However, I'm not pessimistic. I work in different countries-- like I said, nine countries designed single payer. In countries with steeped, vested interest groups you actually have to take steps. And one of the major steps of our citizenry is I think American citizens need to be educated, educated. And I think that's why you are here. But there are not enough of you yet. And you have to get these facts and say you are actually going to benefit, maybe it's $1,000 per person, but a family of four that's $4,000 to you. Make them internalize it. Make them-- give them information that they can argue with their neighbors. And designing a program, how do we help the ones who are going to lose their jobs, or minimize the number of people who are maybe losing their jobs. All these details are not worked out yet. And so, you have a lot of work to do. But it's really exciting. Thank you. - I hope everyone has had enough coffee, their chocolate bar is kicking in, maybe, hopefully, it's not putting you to sleep because I'm going to be presenting some data. And it makes some people a little sleepy. So get ready. And I'll try to make this as painless as possible. So first, I'm very pleased to be here with you today. For those who are unfamiliar with the Commonwealth Fund, we are a nonpartisan, private foundation that conducts and supports health policy research. The mission of the foundation, which is about to complete 100 years in existence next year, is to achieve high quality, affordable healthcare for all. We are based in New York City. And we also have an office in DC. So I'm very pleased to be here with you today. So today, I'm going to spend the first half of the talk presenting data from two recent Commonwealth Fund reports. I will first compare the performance of US healthcare system from a global perspective, then compare the performance of states pre and post the Affordable Care Act. The second part of the talk will focus on what we can learn from high performing countries and the experiences of states, and how we can move forward on improving US healthcare in the short term and the long term. And I hope that all of these discussions today will spur some lively discussions like it did this morning. Let's begin by talking about US healthcare performance from a global perspective. As background, it is often said that the US has the best healthcare in the world. Right here, in 2004, George W. Bush said these exact words. But limited evidence supports this claim. We do know that, as this exhibit shows, that the US spends far more on healthcare than other high income countries do. We know that spending healthcare has grown more rapidly in the US than in other countries. And the key question is whether the US achieves better performance given its high level of spending. We've already heard-- you already know the answer to this. The answer is no. In "Mirror, Mirror," our international comparison report, we used recent data to compare healthcare system performance in the US with that of 10 other high income countries. In this report, countries are ranked based on 72 indicators that measure performance in five domains. And data come from our international surveys, the OECD, the WHO, and also other sources. This slide summarizes the overall findings from this report. The visual displays the magnitude of the overall performance differences between the 11 countries included in this report. The performance score is based on standard deviations. It's a common method for understanding differences within a group. And as you can see, the US not only ranks last, but has a substantially lower score than most other countries. This figure also shows that three countries are top performers, the United Kingdom, Australia, and the Netherlands. And keep these three countries in mind because I will be coming back to this at the end of my presentation. The only reason why I'm showing you this slide that's not very friendly to the eyes is that it includes more detailed performance on country rankings and why the US ranks last. Because it ranks last on four of the five domains of performance, which is shown in the rows. If you go to the report, you can see all sorts of details that feed into this table. In the equity domain, which is near the bottom, notice that the US comes last and the UK and the Netherlands rank number one and number two. In these countries, there are relatively small differences between lower and higher income adults on 11 measures. In contrast, the differences in income in the US were especially large on measures related to financial barriers to care. 44% of low income adults and 26% of higher income adults reported financial barriers to care. And this compares to the US where only 7% of low income and 4% of higher income reported these problems. So higher income adults in the US report more problems than the lower income adults in the UK. In the next set of slides, I'm going to shift focus and talk about this inequality and use data from the Commonwealth Fund's Scorecard on State System Performance to look more closely at the difference in state performance. But before I do, I just wanted to provide a brief background to the ACA. I'm repeating a little bit of what was already said today, but this is just to frame the conversation because of one of the things that the law intended to do. For decades, there has been a wide gulf between whites, Latinos, and blacks in terms of health insurance coverage and access. The proponents of the ACA hoped that the law's major insurance coverage expansions and reforms would bridge those gaps by making health insurance more affordable to adults with low and moderate incomes. And of course, this was done through the ACA when marketplaces were established to help families, moderate and low income families, purchase plans on the marketplace with the standard benefits with subsidies and assistance. It also expanded Medicaid to the adults with the lowest incomes. But the Supreme Court decisions made this optional for states. We've already heard this. Because the Supreme Court decisions made Medicaid expansion optional for states, as a result, you can see in this table, that there's a lot of variation about states' decisions about what they did about Medicaid. And I'm not going to spend much time on this table, but I just want you to-- suffice it to say that 31 states and DC participated in Medicaid expansion, so you can focus on the purple and the yellow. And 19 have not. And we've already heard this offers a very excellent opportunity to study the effects of the expansion. So for the next few slides, I'm going to be focusing on the data from the 2017 State Scorecard to show you the impact of states' decisions on Medicaid expansion. First, the big takeaway is this, that during the first two years of the ACA coverage expansions the uninsured rates dropped dramatically across the country for whites, Latinos, and black adults regardless of whether they expanded Medicaid. The gaps between whites and blacks and Hispanics narrowed, as the law intended and hoped it would do. But take a look at what happened in states that expanded Medicaid. I think there's a chart to your left. The uninsured rates are significantly lower for Hispanics and blacks living in Medicaid expansion states versus those adults that live in states that didn't expand. During this time, minority populations also experienced historic gains in their ability to access healthcare when they needed it. In this chart, we're looking at another outcome, whether or not you experience financial barriers to care. Again, I'm comparing non-expansion states versus the expansion states. And what you see here is that across the country gaps between Hispanics and white adults narrowed. There was a smaller share of Hispanics and whites across the country that are skipping care because of costs. But again, if you look at the Medicaid expansion states, Latinos and Hispanics who live in those states are significantly less likely to skip care because of cost than the Latinos and Hispanics who live in non-expansion states. This is the same analysis that points to the black white gap. Among black adults, the average rate of foregoing care because of cost was lower to begin with. And it declined slightly more in expansion states compared to non-expansion states. So this has led to actually a greater reduction in black white disparities on this indicator in expansion states versus the non-expansion states. So what are the key takeaways from these two benchmarking reports from the Commonwealth Fund? So while the US has made significant progress since the ACA coverage expansion, it still lags in comparison to other countries on affordability, on access to care, on equity. The ACA's coverage expansions made a difference for Latinos and blacks across the country. It made historic gains in their ability to access healthcare. And gaps between these groups narrowed. But what state you live in matters. It matters a lot. And still, according to a report that was released last week and to the recent CPS statements, our ACA tracking survey finds that 14%, or an estimated 27 to 28 million working age Americans, remain uninsured. So where does this leave us? Let's go back to what we learned from international comparisons and look at Australia, UK, Netherlands. And what do these three countries have in common? The most important is that they provide universal coverage and access and financial protection from healthcare cost. The US offers the least financial protection, and is the only country, among these 11 high income countries studied, without universal health insurance. But these top performers finance and organize their healthcare in very different ways. This drives home the idea that there does not have to be a one size fits all solution to achieve universal coverage. Let's look at the three countries who are the highest performers. The UK, in the NHS, services are paid for through general tax revenue as opposed to insurance premiums. There are no caps, general caps, but out-of-pocket cost payments only apply to prescription drugs and medical appliances. And low income and other vulnerable populations are exempt from cost sharing, which is why they score the highest in our "Mirror, Mirror" report on measures of equity. Healthcare in the UK is centrally directed and has more direct management, accountability to the government than in other healthcare systems. If you look at Australia, everyone is covered under the public insurance plan that is also called Medicare. Much like the NHS, Australia's Medicare is funded through tax revenue. There are caps on out-of-pocket prescription costs only. And it's dependent on income. But the protections for low income are not as good as they are in NHS and in the Netherlands, which is why you see that they're not the highest performers on the equity measures. Unlike Australia and the UK, the Dutch health system relies on private insurers to fund health services for its population. Everyone with the same insurer pays the same premium, regardless of age and health status. All plans include a standard, basic benefit package. Subsidies are available for people with low incomes. Adults are required to enroll in a plan, or they must pay a fine. This should sound very familiar. This model shares many similarities with the insurance marketplaces that was created under the Affordable Care Act. Clearly, we are not the UK, Australia, or the Netherlands, but we can learn from other countries about ways to achieve universal coverage. I want to conclude with some thoughts on some short and long term strategies that we need to consider in order to stabilize and improve coverage and access in the US. First, we need to stabilize the individual market. We've heard about this. Here are three things policymakers and the administration can do now to help stabilize the individual market. The first, the administration has not made a long term commitment to paying insurers for the cost sharing reductions for low income enrollees in the marketplaces. Congress could resolve this without making-- by making a permanent appropriation for these payments. Without this commitment, insurers have already announced that they are increasing premiums to hedge against the risk of not receiving payments from the federal government. Congress and the administration needs to signal to insurers participating in the marketplaces that it will enforce the commitment to the individual mandate. Again, uncertainty about that-- like the cost sharing reductions-- is leading to higher than expected premiums for the next year. We also need to fund and support outreach and enrollment efforts for the 2018 open enrollment. Latest data from our ACA tracking survey shows that 40% of the remaining uninsured adults were not aware of the marketplaces. CNS announced at the end of August that it plans to drastically cut funding for the ACA advertising and navigator grants. So we know from our research that people who received personal help were much more likely to enroll in marketplace plans than those who didn't. Long term strategies for stability and greater coverage, first, make tax credits and cost sharing reductions available to people with higher incomes. There is a steep cliff for people who make 400% of income or above. Allowing people who earn more than this to be eligible for tax credits could cover an estimated 1.2 million people, according to a Rand analysis. A larger fix, in terms of impact and political will, is that the 19 states that have not expanded Medicaid could decide to do so. Another strategy that's being discussed is the reinsurance program. You may have heard that Alaska just received approval for their state reinsurance program. Now, while this is expected to reduce insurance premiums in Alaska and cover more people, Alaska is really a special case. For most states, this would take until 2020 to set up a reinsurance program. Finally, while it appears that most counties will have at least one insurer offering plans in the marketplaces this year, Congress could consider a fallback health plan option to protect consumers if they don't have a plan to choose from with subsidies available to help qualify enrollees to pay for these premiums. So what I want you to leave with is that there exists a range of options and actions, big fixes, little ones, for moving forward to improving healthcare in the US. And I think as a debate about the future of healthcare in the US continues, I'd like to close with a final thought. More than 30 million people now rely on the ACA reforms and expansions. And there are nearly 30 more people-- 30 million people who are uninsured. I think it is critical that the health of these 60 million people be the central focus in our debates, regardless of which approaches or strategies are ultimately chosen. So I want to thank my colleagues at the Commonwealth Fund for their valuable research. And also, on this last slide, provide you with some resources for your own research and analysis. Thank you very much. - Thank you all so much for your insightful comments and wonderful lessons that you've shared with us. I would like to ask, what policies and conditions from your expertise, be it in California, in nine other countries across the globe, do you believe that the United States could feasibly adopt say over a 10 year horizon? There are undoubtedly an incredible number of lessons that we could adopt at both the federal and at the state levels. And there are undoubtedly lessons that because of economic, or political, or social realities in our country that will be difficult for the United States to adopt. Given your expertise and your years in the field, I wonder whether you could help us understand a little bit better, what, in your opinion, could be feasibly adoptable over a 10 year horizon? - I guess I'm the optimist, or true optimist, here in the room. I'm certainly not going to disagree with Professor Hsiao, but the California dynamic is that you have 13 million people on Medicaid, Medi-cal, once again, and 15 million who are underinsured. And it's a state of 39 million people. Right there, you're at 28. So I'm going to argue that the benefit to this reform is deeper-- it is broad, but it also is deeper. And you have a government that's controlled two thirds by Democrats and a Democratic governor. And that's not likely to change in 2018. So the politics-- in our view, the politics favor this. And you also have the initiative process in California, which can be used both to overturn legislation or enact it. So those factors-- and we came pretty close. The pharmaceutical industry spent $131 million to defeat a price control initiative that got nearly 47% of the vote in 2016. So I take those factors together to say that we actually have a real shot in California, whether it's 2018 or with the next governor. And we're pushing hard for 2018. We still think that this can be the template. And so, all of a sudden, if California looked different from the rest of the US-- for example in those international comparisons, if it looked more like the Netherlands or Australia-- don't think it's going to get to the UK-- then that would be a comparison that then would motivate the federal government to move to a Medicare for all type system much more quickly. That's our theory. - I think that one thing to put into perspective is that when we talked about the single payer Australia and Netherlands is that these countries transitions to this about 40 to 70 years ago. And it took at least 20 or more years to get to that point. And so, we have to operate within that political reality when we're thinking about next steps in the US and the incremental fixes that can be made. I do think that the state natural experiments are very powerful. And will-- I agree with you-- will serve to maybe motivate other states. But it really will have to happen-- for big change to happen it has to happen at the federal level. I'm not on? Thank you. So I think I'll stop there and let Dr. Hsiao give more examples. - I don't have the magic bullet for United States. I would really think there is-- I would divide into three audiences. One is what academics can do. Academics can actually try to apply their knowledge, design something realistically and practically can be adopted, and workout the step by step. I don't think that work has been done yet. And I'm equally guilty for America. I gave up on America in 1993. That's why I turned towards the international work before I tumbled in Washington. Every week I flew to Washington. On the political participation, I really think it's really important how do you engage the citizens, and also understand they really have a stake in it. I will argue business leaders know they have a stake. I know the provost of Harvard, Alan Garber, he faces a difficulty to find the money to pay for the increased health insurance premium last year where our workers, unionized workers, was going to go on strike over that. So business leaders really feel it. But these common people, many of them, may not feel that. And I think a lot of education and grassroots organization are needed. But in terms of policy, I will put forward a few ideas for you. One is trying to introduce a public option, as Professor Carpenter pointed out. Originally, actually give people a public option and you can voluntarily enroll. And now, we have ACA in place, but some places, there's no-- there are very few insurance plans being offered to people. And the competition doesn't exist in these places. Why not use a government option? Say, this is what the public can offer you. And you can buy it. We are not mandating you have to buy the public. Second, since Medicare For All is going to be a very attractive option, and is a wonderful political slogan, Medicare is not perfect. Medicare, the benefit package and the payment system needs major, major change. I was involved in late 1960 design Medicare. We know where we fell short. But no political pressure to fill in these gaps. Now when the drug benefit came in really under abnormal circumstances, I would call it. Medicare can be made better. We did not have so many elderly people or nursing home care. We need a long term care policy in America. Look at Japan with the largest number of elderly people. 22% of the population are over age 65. How do they take care of that problem? They pay you if you are wanting to stay home to take care of your mother or father. Singapore, if you buy a house within a mile of your parents', your mortgage rate is reduced. They had all these innovations going around in the world. We don't look at them. We think America is the best, the number one in everything. I woke up, sorry, when I began to do international work. Other countries have work ahead of us, as Michelle pointed out, among all the rankings they gave, Netherlands, Australia, UK. American was the last. They must-- other countries must be doing something right. I would-- so Medicare needs to be improved. Third, there are legal barriers for state to adopt single payer. Like ERISA law forbidding you to say to the employees you'll have to buy certain insurance. That's a barrier California still face. That was the thing we faced in Vermont. We spend money employed and got volunteered the best lawyers in America to advise us how to get around that law. But we are not sure. A lot of these barriers should be taken down as intermediate steps when you move toward better system. Sorry, I talk too much. So we can really take a number of things. And it may take us a decade, but I'm optimistic. I think it's the second presidential election from now, from 2016, that's when single payer is really going to be debated in a very serious way and looking for real, practical, viable, politically acceptable way. Here I-- sorry, I give you my-- I look at policy making in three stages. First-- this came from poor woman's work. First stage is you get some issue embraced as a key issue by some political party or powerful group. Now, Senator Sanders got the Democrat party to do that. But that's a vision, like a beautiful mountaintop. But it's not a policy how do you go from here to that mountaintop. Second stage is to actually design politically viable options for that. Then third stage, then you go through legislation where a lot of horse trading, or you call sausage making, occurs. Then you come up with something really workable. We are, in my view, it's the first stage with the latest event. - Thank you all so much for your helpful responses. I really appreciate it. We will yield the rest of our time to the audience. Just as in the earlier session, please feel free to come up to the microphone. Please introduce yourselves. And please formulate your remarks in the form of a question. Thank you. - Hello? Hi, my name is Alexis Soul. I'm on Medicare. And I have union health insurance. So I'm pretty set unlike many Americans. I want to thank you all for this fabulous, fabulous stuff you're doing. I lived in California for about 30 years. And I'm very interested to hear what happens there. The elephant in the room when Michelle was talking about-- no, no, it was Dr. Hsiao. You were talking about who benefits by the current system and how much money can be poured into these elections. And I think that campaign finance reform is something that we should just always think about and act on at any point. And I guess I want to ask you all about your thoughts about that. - Quickly, we, in 2006, sponsored Proposition 89 because we actually believed that we couldn't win this type of reform without changing campaign finance. And we actually targeted initiatives, not just candidates, for that campaign finance reform. It did not do very well, I must tell you, in part because unions didn't want us to change how initiatives were funded. But we do believe that that may still be a precondition. Though, the experience of prop 61, where we came close despite the big money, tends to create more optimism than we had in 2006. But we agree. That is a key and immediate problem. - Hi, I am-- my name is [INAUDIBLE] I'm a senior at Harvard College. I'm an undergraduate. First thing I want to say is all of you on this panel and the last panel, I want to be a physician when I'm older. And I think I want to go into health delivery. You're all legends. Just like thank you very much for sharing your work. First of I'll say my brother actually works for Oscar Health. And they're trying to enter the insurance market in California. And a lot of these issues that you're tackling are things they deal with a lot. I, myself, I think I'm more interested in Dr. Doty's work, which is international health systems. And I had a pretty specific question about something. You briefly touched on-- and Dr. Song briefly asked-- and it's about the Netherlands and also Switzerland. Those are two nations that I feel-- and I'll keep it short-- they emulate basically what we have here, but they do it right, like you said. You touched on some of the things the Netherlands does well, but both of those nations, I think, are grappling with what we're also grappling, which is an older and increasingly sicker population, and their costs are rising as well. The Switzerland is an interesting example because it's divided into cantons, which is a little bit federalist as well. It's similar to the state structure we have here. I was wondering if you, or others who know about it, could comment on specifically in the short term, maybe not in the next decade, but maybe in the next five years, what are some of the things we could take away from those systems and apply them to the US? Because I do think I'm of the mindset that rapidly overhauling the ACA for a full single payer system is pretty divisive, and having to convince 160 people currently insured under the ACA that the increase in taxes and potential premiums is better than the care they already receive or the insurance they have. - So what I'll say about Switzerland and the Netherlands is from a delivery system perspective they all embrace the idea that it's important to care about chronic care management and do it well, to care about patients who are the high need and high cost. And they designed their delivery system to take care of that population really well. And that means that cost sharing is low. The primary care infrastructure is designed to address long term preventive care for those populations. So they actually are able to keep the costs down for the highest needs and the high cost. So that's one thing. The other thing that they do well is really the cost sharing for low income. In Switzerland, they actually rank with us pretty highly on out-of-pocket costs. But that high out-of-pocket cost really is for higher income individuals. What sets us apart is that we have actually high out-of-pocket costs for low and moderate income families and other countries don't do that. - Michelle, I'm curious about this because we do-- we get this debate quite a bit actually. My understanding of those systems is that the level of government regulation and public financing is quite high. And that people think that these systems are the same, but actually in some fundamentally-- politically, in some fundamental way, they're very different because the role of government is far beyond what even is standard in the US, certainly. And I wondered if you could comment on that political difference. Because it seems like they're heavily regulated systems in that sense. - They are. I think that the ministers will have heated debates when they're developing their budgets about how the money is going to be spent throughout the system. And I have to say that from the international perspective that they actually also come to us to learn about bundling and bundle of payments and the ACO and lessons learned from there. So while I like to say, oh, we have so much to learn from other countries, that there actually is a lot of cross-fertilization of ideas because they are grappling with how to contain costs just as much as we are. - Can I throw a sour grape into this discussion here? The countries you mentioned, Switzerland and Netherlands, the highest costs among affluent countries is United States, more than 17% GDP. The second one is Switzerland. The third one is the Netherlands. So if you are looking for efficiency, you may not want to do it, but for practical reasons, political reasons, you want to look at them closely. And you are right. Netherlands went through a whole 10 years really bring the private insurance under control. Pooling the risk nationwide. Before it wasn't. And now, you pay the premium to a central fund. The insurance collect the money, but go to the central fund and then reallocated back with the risk adjustment. But also, what they paid to the providers are highly regulated. But they give them some room for flexibility. - So my question here is given that level of regulation and government control, is that really going to generate less of a political fight by the industry interests? That's a question, I think. - My name is Katherine Arrott. And I'm on the board of-- Massachusetts has 27 regions to provide in community care for the elderly who are low income. If we go back into the early 2000s when HIV, we got our first drugs. But they were not affordable except to the very well off. And we wanted to share those drugs with the rest of the world because they did not have them and they could not afford them. And so, we approached and we lobbied the drug companies. And they finally conceded, yes, they would consent to selling the drugs at a much lower price provided their patents were protected. So you can reach out to the drug companies and work with them. And I would suggest-- now, one of the issues is with the genome having been fully-- not fully explored-- but that's why everybody in the drug companies are rushing forward to develop new drugs. That takes money. So they've become a place of great investment where there can be tremendous return if they are successful. The drug companies are in all of the top 10 sections of endowments, mutual funds, and everything else. And I think the only way to get that under control and still allow them to get the investments they need to continue their work is to treat them as a utility and say you can have this percentage of gain to do with what you want, but you cannot continue to raise your drug prices through the ceiling because somebody will pay for it and then re-invest in us because they want to improve their endowment. I think that's a discussion that has to be had on a very broad across because the times have changed from how drugs could be so successful. What do you think? - I'm a reader of the Marcia Angel's books on pharmaceutical industry. So I have certain bias. 10 years ago, I did look at the financial reports of the big pharmas, five major companies. The argument that if you reduce the price, or allow regulation of price, then they are going to reduce their research, to me, is a scare tactic. If you look at detail what they spend for marketing, advertisement versus how much they spend really for research, they spend equal amount on that. And if you look at the past decade-- I'm not a student of the drug industry, but I follow a little bit-- so much of the new inventions come from small companies, and then they buy it. So it's not-- I think, yes, we should be very careful not to deny- to worry about it-- we do want to keep innovation and invention. But I think the case made by pharmaceutical companies is exaggerated. That's my-- And how do you do it? Look at England and Germany. They are countries with big pharma-- and Switzerland. They negotiate with pharmaceutical companies for prices. Did that-- so many drugs that they discover in England. England is a major inventor and production of drugs. And England doesn't let pharmaceutical company just charge whatever they want. Now, of course, American company's defense is to say, well, that's why we have to make more money from Americans. - So we can subsidize the UK? - Right. - OK, thank you. - Hi, I'm Bria Dunham. And I'm faculty at Balton University and the Director of our Undergraduate Health Science program. You all acknowledged some of the political thorniness involved in moving from where we are now to a single payer system, whatever form that takes. And I was wondering if you see any way forward through that thorniness that is attuned to issues of reproductive justice, particularly in the form of securing publicly funded abortions. - Exactly. Two things, one is SB 562 does that. We publicly fund abortions, but more interestingly, so does S 1804, the Sanders bill. It actually overturns the Hyde Amendment. And it's quite unique because the other single payer bill in Congress doesn't do that. And that was a conscious policy decision. That it would be-- it was assumed to be easier politically not to do it, but it was not acceptable as policy to do it. And so, we think it's very significant that both the California and that federal bill go right and say, yes, we're going to cover reproductive health services, including abortion. - Hi, my name is Gabrielle Amascolo. I'm a retired pediatrician. And I want to say thank you to all for this such informative presentation. And to you, Dr. Hsiao, I'm going to ask that you don't give up on us lowly Americans because we're not the ones you went to talk to. You went to talk to that group on the right side, the black money group, who obviously doesn't want to hear you. And so, I think the information you gave us-- it's a complex issue, but the information and those numbers you gave us are very easy to understand for anyone. So I think that I would love to see some research groups, some of you maybe, really give us lowly Americans the steps that we have to take to climb that mountain to change because obviously we did it with ACA. Nobody thought that that was going to be good through one vote. And we worked very hard on doing it. So I am really not totally lost control of this, but I do think that we need to have education to us to really move onto the grassroots in every nation-- every state rather-- and we need help. We can't do it just this small, indivisible groups, or whatever groups we are working with. We need help. And I'm looking to Harvard to give us that. - Thank you all so much for your questions. Let me now turn it over- - Thank you very much. So it's my privilege and great challenge, given the fantastic material that we covered all afternoon and the great variety of it, to summarize for you. So I would say in the first panel we talked about how the ACA and Medicaid, though they're not perfect, really have a branding problem. So we talked about the ACA, despite its near death experiences, has achieved historic lows in uninsured Americans. And that despite the assumption that Medicaid is broken, many of the patients who receive it are actually quite happy with it. It feels instead as though the problem, or one of the problems, is that millions of Americans don't even know they're on Medicaid. We have MassHealth. We have Kynect, Medi-cal. That's a branding problem. We also have, apparently, hundreds of legislators who don't know what these programs are. They don't know what the programs cover, like long term care or opioid treatment, who is covered, disabled children, and as they discovered, not just low income individuals, but also much of the middle class. They also discovered that the importance of the ACA, and of Medicaid, as fundamental economic pillars of many of our communities, as employers, and also because, as Dr. Benjamin noted, that a healthy population makes good business sense. And so, for all of these reasons, I think our legislators heard this summer when citizens rose up to protest. We also talked about some paradigm shifts. We talked about the current fragmented system that's risen from our industrialized, market driven medicine that leaves us with high administrative costs, high drug costs, and an imbalance between specialists and primary care that would really lead to an improvement in public health. And that we may have $1 trillion wasted every year. That is quite a number. We're talking about a paradigm shift, one that emphasizes prevention over treatment, and one that really recognizes the profound social determinants of health. We heard, in the first panel, about Boston Medical Center's programs to work with the community on food pantries, on housing, on jump rope challenges. But Kate Walsh also said they can't be all things to all people, which brings us back to the question of who's responsible and of citizenship. We examined citizenship at many levels. We talked about states as citizens in the federal system, and that the federalist system itself can be leveraged so that states can test adaptations as proof of concept and as political strategy. So for example, we had Romney care here in Massachusetts that was something of a model for Obamacare. And California, I hope, can hit the ball home for us and really inspire the rest of the nation. But we also talked about political economy and political reality and some sour grapes. And Dr. Hsiao gave us a dose of reality that there are very powerful, vested interests behind these choices. I thought this was an interesting point that there are many small winners across the citizenry, but a few very powerful losers. And because of this, everybody needs to be mobilized, educated. Everybody needs to learn what is at stake as voters who hold our legislators accountable, as employers, as healthcare professionals, as academics, and as advocates. Different sectors, the only way we can do this is for different sectors to come together to solve these problems to elevate health as a shared value that reflects our commitment as a nation to justice, equality, and democracy. And with that, I thank all our panels from today. And I thank you for your fabulous attendance and questions.

Election results

Candidate Party Votes[2] Percent
Simon Larned Democratic-Republican 1,241 61.9%
Daniel Dewey Federalist 765 38.1%

Larned took his seat on November 5, 1804, at the start of the 2nd session[3]

See also


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