It Depends What State You’re In: Policies and Politics of the US Health Care System | Part 1

It Depends What State You’re In: Policies and Politics of the US Health Care System | Part 1


[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]

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