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Sixtieth Texas Legislature

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The 60th Texas Legislature met from January 10, 1967, to May 29, 1967, and again in a special called session from June 4, 1968, to July 3, 1968. All members present during this session were elected in the 1966 general elections. The Democrats retained control of the Legislature.

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  • ✪ It Depends What State You’re In: Policies and Politics of the US Health Care System | Part 1
  • ✪ A. James Manchin, excerpt from "Different Drummer


[MUSIC PLAYING] - 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 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 debate over health care. For much of the 19th century, 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 extent to which government protected individual rights. In other words, the benefits of citizenship very much depended on where in 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 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 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 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 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 an 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's 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 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 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 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. Any one 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 proposal. 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 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 immense 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. [APPLAUSE]



Party summary


Affiliation Members Note
  Democratic Party 29
  Republican Party 2
Total 31


Affiliation Members Note
  Democratic Party 143
  Republican Party 7
Total 150







External links

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