It Depends What State You’re In: Policies and Politics of the US Health Care System | Part 2
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It Depends What State You’re In: Policies and Politics of the US Health Care System | Part 2


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

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