IHPI Special Topics Seminar: The State of the Health Care Debate with Jonathan Cohn / HealthChoice

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we're going to get started there's a little enemy in the back of the room she doesn't move your way up front and sit down we want to go and let our presenters get sorry fell off stuff to talk about something talking about happening in the last five minutes just looking over there providing this pulpit great happy hour here today is dozen columns he's a senior national correspondent in Hopkinton quote he

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writes about politician policy with a focus on social welfare he's also the author of 60 untold story of America's health care crisis and the people pay the price Johnson work particularly the New Republic and American Prospect and encrypt from the Atlantic York Times Magazine and self other publications this journalism is one of awards and the Sidney Hillman foundation that Association of healthcare journalists world hunger here and the national musical of the caucus he's a graduate of Harvard a phone call with emails and Henry J Kaiser Family Foundation and a

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member of the National Peggy Social Insurance his other green to fame is that he is married to IH bi leadership team member in homes of humane over Amy is the type of research centers go to FBI called chest which is the center for healthcare engineering and patient safety and time chefs and Amy oldest organized list so we appreciate that collaboration one last comment before I turn it over to Dobbin is that if you're

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tweeting about this event we'd like you to include hashtag iep/ifsp and thank you thank you well this is different so yeah you know usually when you agree to give an academic talk the great virtue is that it's a chance to get out of the daily bustle take a nice pause to see the big picture not to get too caught up in the new cycle and I am literally telling it as not making this up when I say that what would Caroline

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just said I was literally rewriting parts of what I'm going to tell you because between the time when I got in my car an hour ago to pick up where's Peter here's Peter of my 13 year old and dropped him off with his mom his mom hi sweetie the story changed and then changed again and I'm fairly certain it's going to be different by the time least the politics of healthcare that by the time I'm done with this talk it will be different than when I start so I would urge none of you to to to to treat anything I'm about to

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say that seriously well maybe I should rephrase that Joanne just assumed is going to be a permanent state of condition also if I found those who know me I tend to talk a little fast I'm a little twitchy I'm talking a little more quickly and a little touch here because I've had seven cups of coffee so 7:00 a.m. and you can vouch for that or actually you can't you only were there for the first four okay so where are we um we are at a very important moment again literally in American health care and I don't actually think I'm exaggerating when I

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say that the next 12 24 48 hours could have like a profound impact on the direction of our healthcare system because we are about there's a bill that the Senate is taking up the Mitch McConnell walk out of his office a few minutes ago and said yes they're going to vote on it next week and how that vote goes depends a lot on how people react to a new version of it they came out this morning and having watched this play out before in Congress I can tell you that sometimes these things are very closely run of affairs and it could go

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either way and it's entirely possible that you know one senator declaring I'm for this to be what it takes to push it over the edge and kind of create a stampede of support or one senator going against it could have the opposite effect and cause the bill that's before Congress to fall apart so it's really a very very critical time and really enormous stakes so the title of my talk I think is the state of the health care debate we should call it the changing state or the uncertain state

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but because that's what we're talking about I need to give a little history but I'm going to do it super quickly because I know some of you know it already and the more important question is where we're going from here but you can't really understand where we're going you can't understand the debate and what's up for what conversation if you don't know how we got here so let's start with we're going to do healthcare economics as quickly as possible and there are two central facts of healthcare economics that everybody should know and you may know this intuitively you may not but the first one is that health care is really

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expensive really really expensive you get sick if you get injured if you have a chronic condition the cost of that medical care is going to be more than almost any single individual and I'm willing to bet every more than any individual sitting in this audience right now can actually afford on their own in other words we didn't have health insurance and we were asking every person in this room to pay for their own medical care on an ala carte basis and any of you got sick seriously and if you seriously injured yourself and if you had a chronic condition you would be

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wiped out financially you would be bankrupt and it would basically be a question of do you skip your medical care or do you not pay your rent and that's what we're talking about that is a fact of life that's because medical care is very expensive it has been that way since the 1920s which is when our modern insurance system began but it's obviously gotten much worse over time so that's the first guy you need to know the second fact is that the distribution of medical spending is highly uneven now I just was explaining how expensive

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medical care is right the fact matter is at any given time you know in this room for example guess where we go about 60 people here maybe is that seem like a good guess someone who's good with numbers is look like about 60 people here all right so what's 20% of 60 that's 12 so guys all right yeah that's right okay so they give you know this moment is probably about 12 people in this room who are largely responsible for almost all the medical spending at this time in this room that's because at any given time most people are no typically good

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health most people don't need a lot of medical care but for those 12 people it's very extreme and so the question the sort of central challenge of medical care of medical care financing is always what do you do how do you get those people the care they need whether it's the routine care going to the pediatrician getting the routine tests getting care for chronic conditions or emergency care heart attack cancer injury what have you and the secret is always some kind of insurance arrangement you want to spread that risk again because unless your name is Bill

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Gates or will just stick with Bill Gates unless your name is Bill Gates you really can't afford that out of your own pocket so getting groups of people together to contribute into a common pool to pay that cash that's the way you do it that is the best way to pay for medical care is the way is done everywhere in the world now when I say everywhere in the world is an important little asterisk on that which is that every other developed country in the world decided a long time ago decades ago that the for their purpose is what they thought the best way to do it was was to get everybody

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pooled together you live in the country you're part of it so you live in England everyone in England's going to pay into this one pool you live in France everyone in France because it's Japan same thing wherever you go on the velcroed everybody pays into one common insurance pool so everybody is sharing and because everybody is in this one group the the government has to sort of administer this to everybody and the government has certain power right so the government says all right we're going to make sure that everyone has insurance and we're going to dictate what that insurance looks like we different countries do it differently

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some countries let people pick different levels of coverage some countries let you actually pick from private insurance providers who are reimbursed by the government but one way or another government's basically defining a basic set of benefits that everyone's going to get the government's going to pay for this is going to raise taxes and might you might contribute with premiums separately but basically one way or another same way you pay income tax today pay for the fire department you pay for the schools you pay for national health insurance now like it's expensive obviously remember how expensive healthcare gets so the government takes it upon itself to

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regulate prices set budget and so if you are in Germany or Sweden or any of these other countries and you are a provider of medical care you're a doctor you're a hospital you're drug maker one way or another you are not just dictating you're not just putting a price tag out there you are dealing with the government or a government intermediary who is either bargaining with you or just dictating to you this is what you're going to make this is per service is how you're going to get paid and that's the character basic broad characteristics of all of these other countries we here in the United States did not do that and there's a long very

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interesting historical story which when I first thought I was going to give him the speech I was going to spend half the time telling you I'm not going to do that you can read it in the bookstore you can find a video of a speak lecture I gave last year when I did that but basically the stories we did not end up with that kind of system instead we ended up with a very different kind of system we have a fragmented system the assumption is that most non-elderly adults will get private health insurance and they will be responsible for getting it on their own and for most people that'll mean getting it through an

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employer go to a job you Center for the job the job says here you can have insurance through us we're a nice big group we can buy insurance together get that nice little pooling arrangement where you go through your spouse you know maybe let's say you just hypothetical example you work for a publication that's based in New York but your wife's a professor at the University of Michigan gosh you know spitballing here you know then that might be how you get your health insurance it's pretty good health insurance University of Michigan - by the way and that's now I'm not getting paid for this that's not like a message from their sponsor or anything so that

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takes care of most of the non-elderly population now along the way that that's how that system grew up out of World War two and various reasons why it kind of became popular there as policy decisions encouraged it but you know what spared by the 1960s going to leave a lot of people out the most obvious group was the elderly because they're not working anymore if you're not working how you gonna get insurance through a job right so we created Medicare which covers everybody who's over 65 which covers hospitals and covers doctors description

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drug benefits were added about 15 years ago for years ago 13 years ago a little more than a decade ago and that covered the elderly we added a program called Medicaid in the nineteen sixties at the same time we did Medicare in recognition there were some people who couldn't get health insurance because they don't have enough money although Medicaid at that time was limited it was strictly limited to children pregnant women young mothers disabled the elderly who could use it to

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supplement their Medicare it was not seen as a broad way of covering most low-income Americans it was therefore sort of spot duty on what society at that point considered the most deserving of the poor and that how our system grew up now they're missing from these groups were people who were working age didn't fall into one of those categories for Medicaid and had to get insurance on their own to buy insurance on their own and and in general a lot of them couldn't get insurance there were two

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reasons for that what was a lot of them just couldn't pay for it again insurance is very expensive to give you a sense of today most people today have no idea what health insurance actually cost because it gets through an employer and your employer pays most of it so you don't realize you know how much you're paying for it but you know a couple thousand dollars a year first a single person's policy is totally typical if you're making $20,000 a year finding $4,000 to pay for health insurance policy is pretty much not possible to do so I'll be able to get insurance because they couldn't afford it but there was a whole second problem

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which is that the insurance market for people who weren't part of employers was run very differently than the part that was run for employers and the following reason insurers discovered very early on if they went around selling insurance policies to everybody one on one the only people who bought them were people who expected to get sick which makes sense right I mean if I tell you you're going to buy insurance you can take it you can leave it if you know you have oh you know I you know I'm prone to a high blood pressure or there's a history

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thing on my family or gee you know I'm a cancer survivor you're going to want to buy that insurance you want to pay a lot of money for it cuz you figure there's a really good chance you're going to need it but you're 25 you've never had anything beyond strep throat you're thinking do I really want to pay $4,000 for insurer you're probably not going to and so insurance companies we get this situation where they go from person to person they'd only get people who were relatively high risk came very expensive to maintain those policies and so to ward off that problem which is known as an adverse selection they started the practice known as medical underwriting they would sort of

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screen you are you you know are you high-risk what's your medical history all that and if they decided you are at risk of generating high medical bills they would charge you more money that would withhold your benefits or they would deny you coverage altogether in addition insurance had total leeway in most states to sort of vary what they actually offered you so you know they would sell you a policy but it's not clear the policy would cover everything in general when you get a employer policy you can be reasonably confident it will cover most of the things you need there might be arguments about

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experimental therapies there might be you know as you get into sort of intensive treatment you might get arguments over whether this specialty visit or this drug but in general you knew that would cover the sort of wide variety of services when you were buying coverage on your own in the old days it was very common to buy policies only to discover that wait a minute there's like no mental health benefits or a very limited one or it didn't cover certain tiers of prescription drugs habilitative services was another common thing left off and of course maternity care was left off that was one insurance

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companies very commonly left off because you know that was something they found if they sold policies with eternity what they got was an unusually large number of people in their 20s and 30s particularly women and they ended up having to pay out maternity and you know it's not a value judgment on the insurers to say that from an economic standpoint they couldn't make it work and that's the sort of problem though nature of the way this insurance market works so that was the situation we found ourselves in in the 70s and 80s when around that time American health care started to get much more expensive than it had ever been before

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employers are struggling to pay for people paying on their owner struggling and we see the number of people without health insurance in this country starting to rise which was a reversal over you know from the 1920s up to about the 1970s there was a steady increase in coverage I mean we didn't have universal coverage like they did abroad but you know we were kind of inching our way towards there is a around the 70s that progress turns around easy to start to fall off and that's beginning of this long discussion of well what are we going to do about

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health care what can we do both to get more people access but also what can we do to control the cost of care so it's not quite so expensive as it's been before you know what can we do about the overall burden this is placing not just on individuals but on employers on society as a whole this discussion kind of went along and you know one idea was that the private sector just kind of absorb this do it itself you know the employers would find ways to make their policies less expensive and that actually they they had some success this

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was the era when they introduced managed care which if you're young the idea that you're have a network of providers probably seems pretty normal most people today you have an insurance right you'd know to check your network to see oh is the doctor I want to see if I need to specialist that doctor on my network 20 years ago that was like a new thing and people were very you know not used to that and in fact it was very controversial unto this day you know there's a lot of controversy over the extent to which our insurance companies using this to hold down costs are they using this to limit access to care but that was you know that was one of the

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ways insurance companies figured out to lower cost in other words the sort of shift more cost on to the individual was figured out very early on that if you ask people to pay a greater share of their medical costs they're going to use less them right that's kind of intuitive so if I tell you you know I'm going to you can you know that a doctor visit is ten dollars and you kind of have a bit of an ache in pain the theory as well you know why not it right and go to doctor ten bucks no big deal I tell you it's a hundred dollars then you might think oh do I really need to maybe I can sort of you know maybe I can kind of put

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up with this or maybe you say well yeah I'm gonna doctor but I'm going to try to find a cheaper doctor as cheaper fees now doing that has an upside and a downside it does mean people will tend to spend less which is what made employers happy and made sure is happy the catch is a lot of times people will skip care they need I mean it from a health care standpoint I don't know how many of you are public health people as opposed to economists public health people and economists and have very different views on this particular question you'll discover doctor an economist is like yeah you know you know we need more want more more cost sharing

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more out-of-pocket costs and encourages cost discipline and the public health people are always there waving their hand saying excuse me excuse me public health person here yeah it's real nice that people are like you know not spending as much on their health care but we noticed that when people don't get their health care like the things they don't get include like their high blood pressure medication which is like really bad for them and then they end up in the emergency room with a heart attack and not only is that bad to them but also a cost for - maybe this isn't such a good idea and this is one of those debates that goes on and on and on but anyway that's how the private sector dealt with this

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problem well eventually Bill Clinton was president he can okay he and his wife Hillary Clinton came up with a plan that was designed to deal with all this it didn't pass but the gist of it was it was an attempt by the Democratic Party to say all right we want to get to universal health care but you know we've been kind of bang in our head against this since the 1940s and we can't seem to pass anything and part of the reason is that you know trying to create what they have over in Europe kind of a what would be long people would call a single-payer system but some kind of really centrally run national healthcare

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system this is hard to do in this country politically a single-payer system and national health insurance system like the kind I was describing at the beginning that would be a pretty radical change from what we have today and it would really change the incomes hospitals drug makers and doctors and you know you may not have noticed this if you don't pay a lot of attention to politics but it turns out that like the drug companies actually have a little more power than most people in Washington just you know who knew right so drug companies hospitals and they

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they like if you like say you're going to take away some of their income they get kind of angry and they start calling members of Congress and saying hey guess what we heard you might want to cut our income and that's fine we're really totally totally a hundred percent okay with that by the way we're writing these really big checks whoever's going to run against you in the next election and members of Congress kind of tend to think twice about that kind of stuff so you know the lobbying power of these interests has made it very hard to pass something else in addition that there's

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a lobbying group called the American public and you know if you wanted to propose to create a European system like system here it's something in will deserve if you ask a poll question and and and and and people do all the time do you think we should have a single-payer system which the government just give Medicare to everybody it pulls off the chart everybody likes that because everybody likes Medicare and by the way on paper I will tell you I've been to these other countries they are great systems there is a totally authentic intellectually honest evidence-based case that those

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countries are getting much better health care for much less money than we here in the United States are however that whole question does not capture the full extent of public opinion because the next part of that conversation becomes great we're going to give everybody Medicare hey by the way you with the nice insurance from the University of Michigan that's not going to be your insurance anymore you're going to get and all a sudden everyone it would employer insurance starts to get twitchy and then you start to see ads on TV and that's not to say you couldn't do it here but the point is that feelings are very complicated and

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attempting to sort of change the system over runs into a lot of political resistance it's also difficult from a policy standpoint because every part of our health care ecosystem is built on the assumption that the reimbursement system will look like it does today they're used to getting paid the way they are paid now and at a level they are paid now if you look at single-payer health insurance systems government-run insurance systems there's a myth out there that the biggest reason they say that that we are health care is so expensive is because of the

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administrative waste that's a part of it for sure and actually again a having spent time over there that I think the best advertisement for single-payer is to go talk to a doctor in France I did this once I remember I was interviewing this very prominent physician in Paris and like I walked in the off and there was like no staff there and I'm like what's up with this you know you're like this prominent doctor there's like to have like a part-time receptionist so like yeah I don't why would I have other people Michael don't have to do billing like like what's that you know I mean it's so easy we have all this overhead here however there's a

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saying that every dollar of waste and health care is also someone else's income that money is the whole our whole ecosystem our whole healthcare ecosystem is key to these large fees so the real reason those systems abroad saves so much money is that they set these really low they tell doctors like I was big Guinea here's how much you're going to make they tell the hospitals here's how much you're going to make they dictate to the drug prices drug drug companies this is how much you're going to make and that adjustment from where they are there to where you'd want to go it's pretty big it's a hard hard

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transition to make quickly something you can do over time but not easy to do quickly so recognizing all that Democrat the powers that be in the Democratic Party for better or for worse not for me to say but you know they made a strategic decision roughly in the nineteen eighty ninety so that all right we're not going to try to just tear down the whole system as it exists our goal is going to be get to get the universal coverage maybe give the government more power like they have overseas but nevertheless to kind of work within the constraints of what we have already and

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try to adapt this system rather than blow it up and that evolution eventually kind of filtered through down to what became the Affordable Care Act which became law in 2010 after a long fight and and really became fully implemented in 2014 and the approach of the ACA I assume you guys are reasonably familiar with it but just to do a quick review again the idea was to leave Medicare largely in place there were a lot of changes in the way Medicare would pay for services and the way the government

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would pay providers in Medicare but there are no changes to the benefits and it was done fairly carefully in a way designed so that the people who are on Medicare wouldn't really notice these changes in fact probably if you asked someone who is on Medicare how did the Affordable Care Act change your insurance the answers they probably don't know but if they did notice the one change that probably notes was the prescription drug bills went down because the ACA added money to help them pay for prescription drugs there was a

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so-called doughnut hole in the prescription drug benefit of Medicare and the Affordable Care Act helped close that so from the standpoint of that beneficiary at least Medicare really didn't change much sort of the same for employer insurance there's a little bit of a wrinkle there because the Affordable Care Act did call for changing the tax treatment of employer benefits and that sound really wonky but basically one of the reasons we have an employer system as strong as we do is that the government gives extra tax breaks for it and starting with the Affordable Care Act they limited that tax break and this is

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one of those things that everybody hates except economists everyone thinks everyone no one wants to mess with that tax break except for economists on left and right because economists are in like unanimous agreement doesn't matter if they're liberal or conservative that that tax break ends up giving you incentive to get more generous insurance than you probably really want to get and that's money that comes out of your wages and we're all better off if you don't get that tax break which you know if you're an economist makes total sense and if you're like not an economist you're like wait aren't you just giving me less generous health insurance and

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you know one of these debates that goes back to the affordable character that but other than that it didn't do much to change employer insurance except it did add a few consumer protections for example it eliminated lifetime and annual limits on benefits which is one of those things that probably quite possibly quite probably nobody in this room or at most one or two people in this room will ever matter to them because very very few people have health care bills big enough to exceed an annual or a lifetime limit on health insurance thing is for that one or two

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people pretty big deal you know we're talking children born with serious birth defects they will need a lifetime of care we're talking about there's a woman I interviewed and wrote about a couple months ago out in California who has an aggressive rare form of cancer she blew through a million bucks after about four or five months of treatment and for these people people like that there's not many of them I mean there really not many of them but for that small class of people having an annual or lifetime limit it is the ability it's

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deserting being able to pay for your medical care and not full stop so that but those are the only changes to employer insurance those are the only changes to Medicare you'll notice that I just described the two parts of the health care system that are probably the most popular maybe you ask people what works on our health care system let's go say well like my employer insurance I'm glad Medicare is there and actually Affordable Care Act doesn't do that much to them certainly not a lot of visible changes and even the invisible changes are smaller and kind of operating in the background where the ACA really did a lot of work was into whether areas the first is Medicaid

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remember I said that when Medicaid was founded it really applied to sort of very narrow groups now over the years various it was expanded and various States took advantage of opportunities to expand it more particularly what you would call the blue state places like Massachusetts California Minnesota and they would tend to expand Medicaid to cover more services and more groups partly because there was a greater need again as remember we were talking about how health insurance was deteriorating employer insurance getting more expensive there more and more people

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going uninsured in more more states showing up in the emergency room they're getting uncompensated care because an emergency room has to they don't have to give you like full diagnostic I mean if you show up at the hospital they don't have to give you like a whole graph of services but if you need emergency stabilizing care they do have to give you that and that cost the hospital's money so that money would eventually end up costing the state so states gradually started expanding Medicaid programs on their own but it's very piecemeal and only in a couple states the ACA said look Medicaid is a comprehensive insurance policy it's dirt cheap for the

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people who have it because there's almost no cost sharing you have Medicaid you pay at most token amounts of money for doctor visits and prescriptions on the theory that you're talking with people who are at or just below the poverty line I mean these are people who can't pay rent can't pay food so you know there's something I could be able to pay for medical care so it's cheap for the beneficiaries also turns out to be very cheap to run for person now there's a reason for that many K doesn't pay a lot to hospitals and doctors per person and this is one of its problems

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is that if you need to get a specialist on Medicaid it can be a little difficult because specialist physicians won't want to take it because it doesn't pay a lot but you know overall the evidence on Medicaid is that it's very cheap to run it provides good cost protection to the people get it it does seem to provide better health although the evidence on that is mixed up so we want to ask me a fun question we can go down the rabbit hole of the oregon health insurance experiment at least four of you are nodding so you know what I'm talking about but you know this is when you get really into fun wonky conversations that eight ten to the rumor to be like what are you talking about in 2/10 we'll be

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like totally invested in but we'll get to that later so they expanded Medicaid medios we're just gonna give them it give States money so they can make decade available to anybody in a household that is at the poverty line or even a little bit above the poverty line and if I was really good at this I'd have those figures memorized what 133 percent of the poverty line is I don't remember offhand but like well I think like 29,000 for a family of three I have to check that anyway it's poverty line just above it you

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could qualify for Medicaid as long as your state opted in that was the key thing originally was assumed every state would opt in the Supreme Court has done decision that gave States more leeway not to do it so today thirty-one states plus the District of Columbia have expanded their Medicaid you're sitting in one of them by the way Michigan is a Medicaid expansion state one of the 31 and then there's this question of the private health insurance market for people who don't get coverage from their employees and it's a funny thing because this is a small portion of the

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population and yet I would say and even don't at most you think about the number of people directly affected by the Affordable Care Act including the Medicaid expansion including other provisions it's probably about a third to two you know between thirty and forty percent of the people are the ones affected by this it's just not that it's important for sure but it's not like the single biggest drain yet when you think about most of what you've read about the Affordable Care Act I guarantee you 80% of its about this set of changes I'm

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talking about the exchanges the individual mandate the subsidies and they get all the coverage and I just say that to remind you all that when we're talking about possible changes to this law this is a very very important but it's also just one part now here's where things got very complicated the theory and who knows what happened if you're familiar with the three legged stool just I don't obviously know the mandates plus subsidies plus regulations if you know it raise your hand all right we'll do a little review for you guys but I'll

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do it quickly so there if you want to give insurance to everybody you want to get everyone into one big pool like I do in Europe obviously you could just have the government give everyone insurance which again is what Europe did is what Medicare does for the elderly if you don't want to do that if you want to provide rely on health insurance you can do that too that's an alternative but it's complicated you need to start with the fact that okay remember we said insurance companies were denying coverage to people with pre-existing conditions they were not always selling benefits that plans that had all the benefits the prices were all over the place you have to tell insurance

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companies can't do that anymore now on you sell to everybody regardless of pre-existing conditions you don't vary the prices based on medical status we'll let you charge a little more to older people a little less than younger people but you can't like varium by more than a ratio of three to one and every plan that you sell has to have ten essential benefits and yes that includes mental health yes that includes maternity care plus prescriptions and hospitalization and all that stuff and you have to do all those things so you're basically dictating to the insurance companies you

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can no longer practice business the way you did up until 2014 now the insurance companies are ok with this in principle they say said alright you know that's a different business model but we know how to do that but we got a problem if you just tell us to do that we're going to run through the whole thing we're people you if we tell anybody hey you can get insurance even if you're sick what's everyone going to do they're going to wait till they get sick before they get insurance insurance companies won't have a way to make money and say if you're going to do that you got to make sure everyone gets insurance you got to have a mandate an individual requirement and

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so the decision was made that the way to do this was to penalize people say if you don't buy insurance that was available to you have to pay a fee to the government that's the individual mandate which you know was the subject of a very big Supreme Court case it's been very controversial and I think it's safe to say has been the single most unpopular part of the Affordable Care Act this requirement so there's that now you impose the mandate you have the regulations on insurance companies and now you're sort of running up the prominently mint you're going to require people to get health insurance well wait a minute let's say we have a family would like making thirty thousand

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dollars a year as a family so a policy for them today is what $14,000 you're going to go out and tell this family they have to pay fourteen thousand dollars for an insurance policies that's going to have six thousand dollars in out-of-pocket spending and they make three that's more than half their income you're asking them to pay on health care I mean that's that's crazy so said alright there's a third stole the first leg was the regulations the second is the individual mandate the third is the subsidies government says alright if we're going to make you get insurance we're going to have to help a lot of people pay for it we're going to have to

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offer tax credits so they fit up the system where if your income is below four times the poverty line for hundreds on the part line which for a family of four is about a hundred thousand dollars so we're pretty high up into the income scale now well into what most people would consider middle-class your income is below that income then you are eligible for tax credits that will make your premiums will be a discount on your premiums the discount gets bigger the less money you have so in effect there's like a fixed percentage of your income you could have to spend on your health

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insurance premiums and then as you get lower into them you can kind of lower kind of closer what most people call working class lower middle class working poor in that range they actually the government's going to throw a little extra money there and say now they were going to help you with your premiums but we're going to give the insurance companies money so they can give you special posit had very small out-of-pocket spending so to give you an example there was a family I wrote about a couple of months ago in North Carolina two parents and a young child don't have

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the numbers exactly in my head but if I recall they had about thirty thousand dollars of income they wife was part-time working part-time in school the husband had used to have a job at a lab and was laid off and was sort of juggling jobs between GrubHub and Starbucks their family income was about thirty thousand dollars there just a little too much money to qualify for Medicaid plus they're in a state that had an expanded Medicaid but because of the Affordable Care Act tax credits they will get insurance for about between a thousand two thousand dollars a year in

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premiums and they would oh no more than a thousand dollars in out-of-pocket costs now that's roughly two to three thousand dollars a year in medical expenses thirty thousand dollars in income that's still tough don't kid yourself but they could afford it and they had actually so happens all three members of family had at least one serious medical problem so for them three thousand dollars rather than their what all their disposal income obviously it was an improvement so that was how the Affordable Care Act was designed to work I came online in 2014 and how to do well

34:53

if you want the positive side of the ledger we have the lowest recorded number of people without health insurance today the number of uninsured plummeted which is what was predicted the CBO had predicted it would get down to about I mean there's different I hate to throw numbers out there because everybody uses a different baseline but what you need to know is that we basically cut the number of uninsured in half maybe a little better and it's pretty close to what the original projections suggested from the Congressional Budget Office from independent analysts the sources of coverage are different than everyone

35:24

expected more people ended up getting coverage from Medicaid less through these private insurance policies but roughly speaking you got lowest number of uninsured in modern times and we have a lot of data to show that people have better access to health care as a result that they have more financial protection and there's some data against just people are healthy others although that's pretty ambiguous certainly in real time and that's just a hard thing to measure and I always try to be careful in sort of saying us that would be the sort of upside people would say the downside you've got a lot of people now paying for insurance that they think

35:55

on the private insurance side in particular would say wait a minute these policies you know they're pretty skimpy I'm looking at three four six thousand dollars in out-of-pocket costs on top of thousands of dollars in premiums yeah I make $50,000 a year I'm a family of three but you know what $50,000 for a family of three income that's not that much money and I you know I got a kids heading off to college in a couple years I got car payments this is not easy so you have a lot of people who feel like the insurance is more than they can afford that has had a secondary effect of making the markets more unstable in

36:28

places because at some point some of these people making 5060 thousand dollars a year and saying you know what I'm gonna buy insurance and who tends not to buy insurance people who are in good health now the insurance companies aren't getting enough healthy bill they have to jack up rates and you get into this cycle where they they keep raising their rates and someone have to leave the states for their and you've probably heard you've probably read that you know there are states with only a lot of places only one insurer there's a few counties around the country where there are no insurers now reality it's a very mixed picture if you go to California actually here in Michigan the markets

36:59

are actually working pretty well and most people have multiple choices of insurance they're relatively cheap most people let's go to Arizona you go to Tennessee gov North Carolina but the costs are really high and then particularly in rural areas you are lucky to have one insurance it's a real you know I think even defenders of the law would agree this is a weakness that needs to be addressed and that is sort of the state of the program as we enter this political moment which is where we are now now today literally we are in

37:31

the middle of a debate over whether to repeal the Affordable Care Act and then replace it with something and that something keeps changing I'm tempted to look at my phone and see if it's changed in the last 20 minutes and and is important understand that the arguments against the Affordable Care Act arguments for repeal a lot of our grounded and long-standing critiques from conservatives not just of the Affordable Care Act but of Medicare and Medicaid and reasons that conservatives

38:03

and don't let think these plans are causing problems for the United States and I would say they are sort of you know broadly speaking part of the classic ideological debate we've been having this country since the invention of the modern welfare state in the early 20th century there is a concern that number one these programs are expensive and getting more expensive and adding an ever less sustainable of system evermore unsustainable ever less sustainable was it this what I do all day I sit and I sit in front my career is it better to say less unsustainable more sustainable

38:34

welcome to my world you know in ever-larger there that's different ever larger burden on the federal budget and that money's got to come from somewhere either we're paying taxes for it we're cutting spending elsewhere we're tolerating higher deficits with obviously has its own effects that is a burden that needs to be met some way somehow there is a sense that these programs don't always work so well that at best they introduce weird incentives into the health care system encouraging more spending in other words they're

39:05

just wasteful I mean Google Medicare fraud Google Medicaid fraud you'll find you know all kinds of examples and there is a you know a sense a philosophical sense also that you know maybe it's not right to ask people who are healthy or younger to pay extra because because there are people who have higher medical bills maybe that's not the right way to do it and there's a philosophical question there as well like to what extent should we ask younger healthier people to pay more the

39:35

bills coming forward now from the Republicans are consistent with that views those views and if you look at the bills I'm going to not you know as you may know the House passed a bill a couple whit months weeks ago now the sentence I'm just going to talk about the Senate bill because everybody I talked to everyone here basically says if the Senate passes a bill the house will just pass that straight the House bill was there to give the House Senate something to rewrite and now the Senate is going to write it and it's not a given but is unlikely the house will try

40:06

to actually change it much so what's in the Senate bill Senate bill number one it tries to undo those reforms of the private market and here's where things really are like up to the minute changes so the bill that was introduced about two weeks ago offered less financial assistance basically said yeah we're going to continue to offer people subsidies to help pay for the coverage but it can be less of money and the assumption is that people will take this and buy skimpier insurance so out-of-pocket costs deductibles co-pays they were high today

40:38

some people think they're too high they would actually on average tend to get higher in the new bill because people have less money and the assumption is we've given less financial assistance to buy insurance they would end up buying a less generous policy so today you were buying a silver policy that would be expected to cover 70% of your medical costs tomorrow you'd be expected to buy one that covers only 58% of your medical costs and that's probably the difference between a policy that has a five you know four thousand dollar deductible in the seven thousand dollar dr. bull or a six thousand dollar deductible and a higher deductible and higher co-pays but

41:09

one way or another you're paying more and out-of-pocket costs at the same time there was an effort to reduce the regulations on the insurance and here's where things change today whereas the new version of the bill includes an amendment that would basically light insurers in a kind of roundabout way which I can explain if you really want me to undo a lot of those so a lot of those new protection so no longer would they always be required to give people insurance regardless of pre-existing condition no longer would they be required to make sure everyone can get a policy with full essential health

41:39

benefits no longer would they be required that every policy had an annual or lifetime limit the wrinkle here is that every insurer would have to offer such a policy still but the way the market would evolve it would become you would no longer be guaranteed access to that and it's complicated to explain it I'm simplifying a bit but just trust me where you can wait three hours and read online at HuffPost where my article will pose that explains all the all the details the unmedicated ills would basically pull back the extra federal funding that allowed states to expand

42:10

their Medicaid programs so remember we talked about expanding it up to 100 you know up to everybody in households with a at or just above the poverty line that's because the federal government puts up extra money because states that you know a bargain says look if you expand it will give you extra money and the Senate bill basically says nope you know as of 2020 we're going to start to call that money back until it's not there anymore and then on top of that the bill basically says going forward we're going to just change the way the federal government funds Medicaid all together today Medicaid is an open-ended

42:41

commitment to basically cover as many people as qualify for the program no matter how much they cover at a fixed percentage of costs so if you're Ohio who you're Ohio and your costs go up the federal government will pay extra to match it as long as you're conforming to the rules of the program under the new system that relationship would be broken there are various options for house 2 different ways States could do this but one way or another that open-ended commitment would end and the projections suggest that given the formulas that the Senate bill has you would see this

43:11

shortfall develop between what states would need to maintain their current benefits and what they'd be getting from Washington and one way or another they would end up cutting their Medicaid programs now there is an upside to all this and there's a downside to all this all just like there was an upside to the Affordable Care Act and there was a downside to Affordable Care Act for were cracks extent expanded health insurance offerings right made it available to more people it's gotten more people health insurance but also increased government spending which means a higher tax burden at some point some way or another introduced market regulations

43:42

that a lot of people think are bad for the economy it made some healthy people have to pay more what would this Senate bill well in the Senate bill actually some of the people who you know if you think of winners and losers some of the losers under the Affordable Care Act would get that back you would see people who are young and healthy people would be able to get cheaper skimpier policies kind of like they did in the old days which for them you know they might think it's absolutely a big win I mean if you're 25 years old you don't want to have to pay for a maternity care maybe you think it's you know it's not you're not you shouldn't have to pay for mental health

44:13

care you know and you could get a much cheaper policy government spending will come down the tax burden would come down the flipside is that you know you to actually lose the protections and the benefits before will correct - you wouldn't see that you something like 20 million people are going to lose health insurance that's going to mean more financial distress less access to health care etc the Medicaid cuts in particular states are almost certainly going to have to pull back and just give you an example of what that would you know two examples of what that would mean you

44:45

know if you think about how this all works out I mentioned you know that family in North Carolina that's dependent on the ACA that story actually also wrote about a family in North Carolina that's paying a lot more for their health insurance today because of the ACA they probably end up saving money under the Senate bill did you know they were they're a little more affluent they're in relatively good health they're probably happy with a they don't feel like they need all these expansive benefits for them the Senate bill is probably a net plus financially at least in the near future you know as long as they don't get sick

45:16

there and there are a lot of people like that the flipside is that other family I described the one that's getting those subsidies they probably end up with no insurance at all and they have like I said a series of serious medical problems and they're going to be stuck and that's the trade-off I mean you can help one group but you're going to hurt another group there's always trade-offs in health policy and so you know the question if you sort want to think of the big picture and already went longer than I wanted to want to wrap this up but you know the simplest way to think about this I always think is it at the end you know we talked about this burden of medical care this burden financial burden of medical care cost a lot of

45:47

money who is paying that and the ultimate question here is who is bearing the risk at the end of the day to what extent do you want to make those responsibility for medical bills do you want to put that on individuals to what extent do you want to say to people it's up to you whether you have the right job and if you don't we know whether you can get the right insurance and if you can't and you have to make up the difference and to what extent do you want to say that society as a whole is going to pick up that responsibility and remember there are trade-offs to both if you do it a former way which is the way that we

46:19

used to do it and the way the Senate bill would would take us in then you are leaving those individuals vulnerable the government is smaller spending is down and you know you have a freer market operating if you keep the system as it is or you move more in that direction you keep moving towards the universal system well the downside is now you're putting that burden on the taxpayers every single person area you know eventually is going to have to support that system you're going to be regulating the private and chain be telling markets how to operate the flipside is that you know

46:49

you get to a system where it doesn't matter if you're poor it doesn't matter what your income is it doesn't matter what your medical condition is you will have access to health care and it's basically a question at the alternate questioners whose responsibility is this who is going to be on the hook here if medical care ends up costing a lot more money than you want is it the individuals who have individual medical bills or as a society and that's really what this debate is all about and if you tuned in in about a week you'll see how it turns out trying to see if any more senators can not against it all right so well I'm

47:27

checking to see we were at two senators by the way the actual you want raw politics here the deal is they need fifty votes in the Senate there's two votes next week there'll be a motion to proceed which means they're going to begin the debate and then there's a vote on the bill at the end because the rules they're using they can do this with fifty fifty no taking only fifty votes two senators senator Collins from Maine and Senator Paul and Kentucky of both already said no we are we are no votes at all was last when I looked at my Twitter feed before I started talking everybody was waiting to hear from

47:57

senator capital from West Virginia who's very worried about the impact of Medicaid cuts on West Virginia senator Heller from Nevada very worried about the impact of Medicaid cuts in Nevada and a couple others and I'm not seeing anything about them yet so as far as I know we are still not sure how this all men turn out there you okay up-to-date news actually so there you go anyway have any questions I think did you want to so you kind of elaborate it really well

48:32

on what I was considered in my huge benefit of the new Senate bill could you perhaps the library on the motivation with current colors you know that I that the other people will have an opportunity or just work in here and families will have an opportunity to a Bellini by not paying a service or services they have facing in the near future okay so um I did to be fair I mean there are you know - first of all because the

49:06

new bill has to go through a CBO score and like this so many moving piece of news I feel I should standards as migrant I can't think it's been Emily how that new virgin shake that has got a couple different bells and whistles in it literally we're also sitting there at Lino's and I'm reading the bill I am talking my economist friends and so we don't know exactly sue me it looks like what we do you know in terms of motivation look I mean I think now why would you me so the question I mean if I can translate your question they trying to show your ad

49:38

page you're moving from a system that offers more protection overall to letter X and that is clearly the case and then it's for the case because you drain money out of federal health programs and that's simply some money shift there's money now going to help people pay for the medical care or through Medicaid through assistance you will find private insurance and also from chain you know a shift in the healthy and the sick and now you're reducing it so that is going to mean less tax so why would you do that well that money you don't have to provide so it's just like it is a smaller attacker I mean I

50:08

think of these parts this is if you really want to you know I think people who are worried about the fiscal burden placed on the budgets are like we need to just you know there's a we need to cut that you know need to cut that off are becoming there's a mentality of is how to list or how to control I think it is the Paul Ryan keg parties mentality a party you know oh my god it's costing so much money if you get a chance to limit how much one of these programs do you jump at it you don't care what it means because it was relevant you know and we can't pay for all this

50:38

so that we went over that's what am i dealing in the philosophical one I mean I do think if you listen and again maybe Paul Ryan open this county records I heard him talk about this a lot and and I am NOT putting value differences there is a principled argument that it's not my responsibility that you know some point I'm working hard and this is my paycheck and I'm you know struggling and why am I suddenly now you pay $3,000 mention something about the knowledge of my shirt I can force it and you know

51:10

there's a large bed floors you really think $7,000 and are you sure you're better to you know you're old but you know that would be icing motivation you know um you know there's it's redistribution I mean many sides this is some people would consider this a chronic public they got personally I mean fundamentally insurance is a form of redistribution it's a form of redistribution from healthy to sick Rachel report and there's a lot people

51:44

just don't believe in that I don't believe that in you know you're going to hate the Affordable Care Act that's what it does Social Security does the same thing you notice that our government programs redistribute and the Corporal Care Act redistributes it does so awkwardly in many ways efficiently and in many ways it haven't worked nearly the way the architects intended but I think there are people who know effective and then you know and there's a principle I think a very principled economic argument but you know what government you know you start messing with market and the ultimate you know general welfare is

52:17

worse off and did that argument it's do I think it's actually important I would say this is true this can come either way to the nine seasons always true to think about not just the health care system when you're thinking about a health care system so you know again when I talk about people were saying we can't spend so much money on health care you know it is a type of like if you're spending while in health care that is that much less it's not on other things now whether in fact cutting the importable care you know when they're cutting them when I have the Affordable Care Act means us to spend more on education for example as a separate

52:48

question but nevertheless I mean they're either thing we do live in a world of limited resource so those I would think of a principle reason I'm not going to speculate on my Google teams life and watch because I can't afford this house seems like a obviously a comment for like a political power shift together way again that true in the inside what would have to give for a settlement like working so I can imagine

53:29

education I imagine - let's say I get two ways is good by three ways to play out so something happens something passes then do we get to this point where there's a little backlash to it maybe no one else you never know how these things go and you can you imagine that system we know a backlash where people who see the opposite viewpoint as imagine Democrats taking the house in the Senate the president in 2020 so let's imagine it's president Bernie

54:00

Sanders or President Elizabeth Warren majority you know House Speaker and you know Majority Leader Schumer do they get in you know whether you know even they all have things that can you imagine a situation where they get into office imagine that where do they get I don't know how far they get in terms of you know creating a different system it's hard to know I mean I might agreed on the politics of this invented bad politics for the Republicans right now

54:36

the calculation a lot of Republicans are making anything and I would be very frivolous Republicans are very much thinking about their political futures when Democrats to the Affordable Care Act they were very much than a public political future everybody thinks about you know the calculation Republicans are making right now is his voting for this bill better or worse for me including Lee and not both I will see you in my read on it then I'm a Republican I am NOT been robbed or a pistol I'm better off by name comment letting us know fail

55:07

you need to talk to them about passing a small bill Republican most then disagree and the reason it has degree of their calculation is that families are problems through on a promise and Tenzing alienating members of their base has a they has a bigger political cost and passing a bill that appears to be very unpopular and there's no way to catch that founders won't ever get to run favorites so I don't know where they end up but you know I would think either way yeah you can imagine a backlash you

55:39

know where that ends up it's so hard to say I do think two things are different anything that there's a lot of actually thing about Brady or regardless of how that's turned out about you can seriously up single payor angle a single parent might get to it and I say there's two things have changed ten years ago twenty years ago when Democrats kind of like been on the tack you know wanted that now we have chance to run an experiment on this sort of public private i grade and what do you think it's been total failure or totally successful even I think the most loyal

56:12

the optimists enthusiast about this what agree it's not as you know it's not achieving what they want that proves help early than they fall it's not getting worse saying they don't would hope so that way create more enthusiasm for it and both politically and as policy so you can imagine that and I ain't even like there was a comment from a CEO that not who I got to tell you I've interviewed him before and he says kind of wild and crazy things and you never be sure that what he said when we say smart gal by the way you know he had

56:46

someone was like well you know we do the benefits for Medicare so maybe you know we could be benefits for single-payer so I made out of this other body part but you know if they're afraid if you come up with a single-payer system provide insurance a lot of role right maybe like in Medicare today people can office private insurance you can imagine variation bases along the way so I don't tell me if I get more of a chance of come swinging over to single payor something like a critical regardless of how this debate turned out in part

57:17

because this debate there are a lot of people a lot of limos and Democrats who were not thrilled with the constituted Korbel Care Act were kind of swallowed hard because like this is the best we can get and we need to do this to make it work and a lot of them are like waiting today we made all these compromises and we're still having these problems I'll shoot my old kind of you know try to shoot them move our spider Jonathan earlier you're talking City focus will be settled in the next few weeks is there a chance it might not be and we're going to be continuing to hear

57:55

this debate for months or maybe for the midterm elections you're trying to get any like running outdoor strange right and like are definitely be like um guys will be debating since forever me what we're going to keep the day healthier when I said so thank you guys now that thing about that's progress is not so clearly in fact a real lesson of the Affordable Care Act I think we've all learned is that this is not nearly as settled as you think I mean I

58:25

remember when they for Care Act passed I figured all right that's why it's over and now we'll go back to the usual back and forth while not really exciting this crazy every night and you know it but you know I mean if this ain't passes I mean this apparently that need Republicans aren't quite practicing in their own calculations I think I made a you write a maybe right passing the bill is still delicious for a movement I don't think they have priced into the stock of packaging bill on the fact that in the same way Republicans did not go

58:56

quietly way after the you know Obama signed up name I guarantee you liberals are going to go away Democrats are to go away from something to bill yes maybe like that obi-wan you strike me down any more powerful so will be debated a lot I do think I need there is one scenario where if we get past this debate though I think is really important setting is an ally possibility which is bill fails

59:26

and you get a bipartisan very small but not totally insignificant bill that sort of short of the system where it's weak throws a little money and insurance companies cover their highest cost people there's there's you know a fund these extra subsidies for insurers that they've not been getting lately and basically maybe there's something an end up Republicans makalah win maybe they get more in a more aged very amazing more flexibility to change things on the state level and insurers they you know

59:59

how they can do three to one age rating out maybe they go for four to one on five and because that's the real budget buster for many works and then we're kind of called it a day and then we're back to the old debate you know in the public in the middle say should block grant Medicare privatizing Medicare watch for a minute made privatizing Medicare shrinks of subsidies and Democrats say we should have a public option and which eventually the single-payer system we should tell the drug companies how much they can charge and we back to that debate which will kill normal which seems so nice right i

01:00:30

or did you sleep okay so you spoke earlier about how it will be much more difficult for people with pre-existing conditions on insurance what about people with current conditions so for example someone who's starting cancer at the time when you wanna enjoy that whole happens there area so that's a good question if you have condition right now you know make sure you count that as a pre-existing condition right we have what happen and so I the way these new

01:01:06

plans all work today you lose your guaranteed access to ensuring it lapses which is true before by the way so you know if you have insurance you can keep it up then your insurance state if you for some reason you drop insurance to lose your job you go from being you know from ones either various conditions that could cause it then once you lose it you have trouble getting it again but the flip side is and this is so important about new asset is that some of the changes very probably would affect insurance policies

01:01:36

that people have even the good ones so remember I mentioned that one of the changes in both the House and Senate bill is that they would loosen the regulations on private insurance because the way that is written any insurance policies attentionally even an employer Bop even the wonderful University of Michigan college you can see a restoration annual my time limits so if you're someone fighting cancer and you know it's very easy with

01:02:06

cancer no it does not take that long get a million dollars a bill I mean quick it doesn't have to be some rare condition either in a system anything like that you can find yourself in a situation where you hit that limit and now you're like now you're stuck and however you say free medical care it's not only careful to say that's not guaranteed they have them in a hassle Senate bill depending on how the assistance the design work the lodges at state discretion it depends on your employer not ever you know in the old days lots of people have insurance policies that didn't have any one lifetime so it's not

01:02:39

guaranteed that well but you you both and you know that's part of the equation Jeremy to get it's more protection yeah the Republican bills would mean less protection . it would also mean much government spending they would be less interference in a free market . and then the check out I mean this is just straight-up trade-offs and that's what it is and not for debate they just want us speaking with us my question pertains to overall health of Americans I haven't been a doctor on the topic so embarrassing that health care reform discussions for understanding the

01:03:14

roots of poor health and you see the protest and in this chicken is optional in tension so we are very health in the country yes there are a lot of reasons for that to have actually not that much to do with medical care the primary determinants of health as I'm sure a lot of people in this room could tell you better than I could income status where you grew up environment medical care as it's currently constituted has very little to do with that that said there are you

01:03:45

know a couple ways that medical care can improve health the first is that it makes you more financially secure you look like lesbian poverty level IV poverty you're less likely to have these problems so I'm going to kind of indirectly like people forget that sometimes you know anything that sort of helps people be more economically secure is going to make them healthier over time you know that in addition there are certainly the Affordable Care Act actually had a lot of money relatively speaking plowed into sort of public health intervention parks now I won't say the

01:04:16

Senate bill does throw a lot more money at one particular College which is treatment of opioid addiction which is a health problem obviously now you're talking to Doug doesn't love the dollars to sort of a lot this sort of a gift here and then there's a tape here and the net was only what less money and to but still do that in your credit we're do one other thing is that there's a lot of innovative medicine out there that really does try to focus on making people healthier and the Affordable Care

01:04:47

Act indirectly subsidizes a lot of us I'm one example just cuz I happen to be active a story coming on this three it's already raised about to expose up in Flint and actually to Memphis a lot of you know the story of the Flint water crisis not everyone knows that you know there's a sort of key moment in that they don't know what's here no Mona these are right right okay so you guys know we're okay so this is a famous one

01:05:19

of the two people who like helped expose when medical rights and water crisis and that's what she had data showing high blood levels among kids emphasis label where'd that come from in the hospital record is out curly medicals are why it is only Medical Center have all this data on life because Medicaid the eat something called the epsdt program mandates testing and pays for testing long images of lead could let is a very big has low-income community probably a

01:05:50

lot I mean I remember he must walk in with like the fingers and go something to houses so less pain to help you out so when you buy how to get lead inspection you know if you're making thirteen thousand dollars a year you're paying nothing for an apartment I promise you this good chance your landlord didn't do the legislation so you know Medicaid mandates that and with it doesn't always work mandate like everything else in Medicaid like to do it they don't but that data was what eventually forced everyone to say oh my gosh yes we have less than one because you member do the White Mountain motor

01:06:19

staying compliant so but I went up to deck says one way Medicaid health health and I kind of indirect way you know whatever the other when I went out of the clinic curly has now a new downtown clinic which is beautiful by the way you guys all been to Quinn it's a gorgeous new building and they actually shook the farmers market one and it has a really cool program where your kid you go to early Children's Center when you leave you get a food prescription a $10 voucher to take next

01:06:50

door the farmers market you can only use it on fresh produce can it on the claim that awesome you know you go there you buy produce whatever and I easily know it's an evil gimmick and partly just say they want to pay they're trying to make coming into the clinic more interesting kind of pleasant experience or what some people come but I think part of this is hey guess what you know you know what I always easily get fresh you know produce diet aren't always great here you going to build these houses down there setting that small fee that actually makes a difference now but I think a clinic all over the country I'm always impressed

01:07:22

and these clinics that serve low-income populations uninsured they have the least resources and some are do the most creative things and you're just always made social workers counselors nutritionist and with the Affordable Care Act extra money they got you there's some work you cover a lot of these places are doing a lot more of that and you know you know about the social determinants of health you know about all this room factors that go into like something has you know having for example counselors who work with families in crisis that actually can do

01:07:54

a lot to improve health right I mean no and I had seen that in sandals Cleveland and Orleans I made them your own couple months ago at a clinic there at like you think of me that's like eating ground zero for a life nutrition obesity you know that anybody will be banned by all walking like a new diet crisis I live but um you know this clinic is like they're really investing all its money in nutrition and counseling like that cooking classes and

01:08:27

knows how much this has actually worked they go study that septum to me those are really promising ways that you can help it and I know I think there's probably a lot of interest in doing more of that I mean you know and by part in a community clinics actually or something that has traditionally promised bipartisan support so get if you get passes for fuel debate in an ideal world you would imaginable where does more money I think if you have to set sorry off now you're way past times a hundred next day [Applause]

IHPI Special Topics Seminar: The State of the Health Care Debate with Jonathan Cohn

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