The Health Care Decision
A panel that discusses the Supreme Court's ruling to uphold the Affordable Care Act. The emphasis is on where do things go from here? The ACA can be broken down into three basic parts: expanding insurance coverage, paying for that expansion through taxes, and bringing down the overall spending on health care.
Festival: 2012
The Health Care Decision
Aspen Ideas Festival transcripts are created on a rush deadline by a contractor for the Aspen Institute, and the accuracy may vary. This text may be updated or revised in the future. Please be aware that the authoritative record of Aspen Institute programming is the video or audio.
THE ASPEN INSTITUTE
ASPEN IDEAS FESTIVAL 2012
THE HEALTH CARE DECISION
Greenwald Pavilion,
1000 North Third Street,
Aspen, Colorado
Monday, July 2, 2012
Soft Scribe LLC
www.softscribellc.com
(703)373-3171
LIST OF PARTICIPANTS
DAVID LEONHARDT
Washington Bureau Chief, New York Times
NEERA TANDEN
President, Center for American Progress
TYLER COWEN
Professor of Economics, George Mason University
Author of The Great Stagnation and
An Economist Gets Lunch
EZEKIEL EMANUEL
Vice Provost for Global Initiatives and Chair of
Medical Ethics Health Policy Department, University
of Pennsylvania, Columnist for The New York Times.
* * * * *
P R O C E E D I N G S
MR. LEONHARDT: What a great crowd, thank you
all for coming. I'm David Leonhardt, I'm currently the
Washington bureau chief of the New York Times. I'm
formerly an economics writer for the Times and I spend a
lot of the last few years writing about the whole battle
over the health care law. Before that I spend a lot of
time writing about health care before there was a law.
And I'm your moderator this afternoon.
You really have three wonderful folks to talk
about this law. And we're each going to talk very briefly
less than 5 minutes each, I promise. And then we'll have
a short discussion among us. And then we'll open it up to
you all, to your questions and comments from you all.
And I probably don't really need to introduce
the topic. It has been the topic that everyone has been
focusing on, not only this week but much before, which is
the health care law, the state of health care and I think
you'll hear from us we're all really going to emphasis,
where do things go from here?
I'm in fact the only one in my brief opening
remarks who's going to really focus on the past, which is
I'm going to try to give you the shortest summary of the
ACA or Obamacare that has ever been delivered.
MS. TANDEN: And when that works we'll show the
campaign.
(Laughter)
MR. LEONHARDT: So I'd say it has four major
parts. The first major part is it vastly expands
insurance coverage and it does it through two major ways.
About half of the expansion in insurance coverage is the
stuff that's gotten all the attention, it's the mandate.
The law says all Americans who can afford it must have
health insurance. And to help them get it, it sets up
these market places where you can more easily compare and
see health insurance and then it subsidizes anyone of
moderate income. In the medium term that should cover
about 17 million more Americans or about one out of every
three people who would otherwise not have insurance.
The second big part of it is Medicaid. They
take Medicaid, which is now a big complicated mess;
depends on what your income, what your family situation is
and it sets a standard on it. As long as you are, I
think, 133 percent of poverty level or below you qualify
for Medicaid. Big expansion in Medicaid. That is the
second half of coverage expansion. That covers another
one in three people who don't have insurance. That still
leaves one in three people who won't have it, a kind of
mix of -- not one in three overall but in that pie -- a
mix of illegal immigrants and people who do not want to
have insurance. That's part one of the law, expanding
insurance coverage.
Part two of the law is paying for that through
taxes, a combination of taxes on high-income people,
raising their Medicare taxes and also taxing companies.
That's part two of the law.
Part three of the law is over the long term
trying to bring down the spending on health care. And I
think you'll hear Zeke Emanuel talk a lot about this. And
I'll introduce each one of the three of them when -- once
I'm done.
And so the idea with that is that it -- it wants
to -- people want to bend the curve as Peter Orszag and
Zeke and lots of other people often say, which is to say
they want to reduce the growth rate of health care going
forward. And the law tries to do that through a variety
of ways, trying to change incentives in health care,
sometimes trying to just cut spending of overall health
care. That is part -- wait a minute, I've got my numbers
mixed up.
SPEAKER: Part three.
MS. TANDEN: That's right. That's part three.
MR. LEONHARDT: That's part three of the law and
what's part four of the law?
SPEAKER: Well, all the quality stuff, reduce
hospital re-admissions, reduce --
MR. LEONHARDT: Right. Improve the quality of
health care regardless of whether it's financial or not.
So try to have a health care system that not only doesn't
grow at the same speed but also provides better results
because right now we spend more than any country in the
world by far. And we do not have better results than any
country in the world by far; it's a mixed bag, we're
better at some things like some forms of cancer care,
we're worse than others. So that's the law, four parts;
cover more people, pay for it, try to reduce the deficit
over the long term, and try to improve the quality of
health care.
The Supreme Court effectively uphold -- upheld
every single part of that law with one significant
exception the Medicaid expansion. They made that optional
for states. So if you remember I said about half of the
expansion in coverage comes from Medicaid. So if every
state opted out of that expansion, which is an option the
Supreme Court just gave them, the law would only cover
half as many people as it otherwise would have. No one
expects every state to opt out of it. The blue states
will not opt out of it. It remains unclear whether the
red states will; you'll hear all of them talking about
that today.
But basically, what the court said is that
somewhere between 50 percent and 100 percent of the health
care coverage expansion that goes on may continue and
parts two, three and four of the law may all continue.
So that's the Affordable Care Act. You can see
why people would not put it on a bumper sticker.
(Laughter)
MR. LEONHARDT: But there it is. And the
question is, where do we go from here both legally and
otherwise? And to talk about that we have Neera Tanden,
who is the chief executive of the Center for American
Progress, one of the most important research groups in
Washington. It leans left or leans progressive as Neera
might prefer I say.
MS. TANDEN: We go with progressive, if that's
okay.
MR. LEONHARDT: Neera is previously the chief
policy advisor to Hillary Clinton during her campaign.
After that she was the chief domestic policy advisor to
Obama in the general election and she was then a top
advisor to Sebelius in the making of the health care law.
Tyler Cowen is a professor of economics at
George Mason University. He's the author of the extremely
well read, Marginal Revolution blog, co-author of it. He
also is maybe the single best source for good food in
Washington. He writes a blog. If you are ever looking
for a restaurant in Washington just google Tyler Cowen
restaurants and he's the author of a new book, "An
Economist gets Lunch."
And Zeke Emanuel is the former head of bioethics
at NIH, he's a former advisor to Peter Orszag and to the
President at the Budget Office specifically on health
care. And is now a vice provost at the University of
Pennsylvania.
We're going to start with Neera. I've done the
past you guys get to do the future.
MS. TANDEN: Great, so I think I'll talk a
little bit about the decision and what it means.
Essentially, just to summarize for those who have not read
about it recently, the decision says essentially that the
mandate, the issue that got the most attention in the
deliberations is constitutional. Chief Justice Roberts
found that it was unconstitutional -- I mean, it was not
constitutional via the Commerce Clause, which I think it
is fair to say had the most amount of energy around it.
There are two arguments around the Commerce
Clause, whether it's just -- is it necessary and proper --
there is a necessary and proper argument, and just a
straight commerce clause. But under both findings -- we
can talk more about them -- under both findings he found
that it was unconstitutional, it was not -- it did not
pass constitutional muster. However, he found that it was
constitutional under the taxing power of the federal
government, which is interesting in that no lower court
found it constitutional under the taxing power.
And now part of that is because courts that
found in favor of the law found in favor under the
Commerce Clause and therefore didn't reach the taxing
power. There was only one judge, Judge Wynn in the Fourth
Circuit who actually said it was both constitutional under
the Commerce Clause and adjudicated. But that was not the
majority opinion.
So it was quite a day on Thursday to find that
that was indeed the rationale. It was argued by the
solicitor general. It was in the solicitor general's
briefs. But it was not a persuasive argument in the lower
courts. So it was -- that is the argument that it was
found unconstitutional.
Now, on the Medicaid issue, as David said. The
Medicaid expansion was found constitutional but the
authority by which it can be the power of the federal
government under Medicaid was limited. So what that was
really -- what the court said really was that the federal
government cannot use the entire Medicaid program as the
leverage point upon states.
So as we all know Medicaid has existed for 40
years. It provides a subsidy of between 50 to 83 percent
to states to provide coverage for this amalgamation of
people. In some states it's relative -- you know, it's --
I wouldn't describe it as generous but it is more generous
than other states, it's only the exceedingly poor, others
are bringing in more working poor people. But that
essentially said to the federal government that you can't
use the existing Medicaid subsidies to cover it.
So right now states have a Medicaid expansion
before them, which they can choose to expand or not for
the first several years of implementation, it is a 100
percent match. So let me just say that again. For every
dollar the state expends, it receives $100 -- 100 percent
of federal dollars for it. It spends no money in the
first few years. It declines to 90 percent.
Now, what I find interesting about that, and I
will just discuss it for one moment because I would like
everyone else to speak is that, what is interesting about
the Court's -- how it has approached Medicaid it is
seemingly more concerned about a regime that provides a 90
percent -- 100 to a 90 percent match, than it is ever
expressed about a regime that was 50 to 83 percent match,
which I find an interesting and odd outcome of the
litigation. And one of the reasons I believe that judges
are sometimes -- it's hard to adjudicate policy issues in
the courts.
MR. LEONHARDT: Thanks. Thank you.
Tyler?
MR. COWEN: I'll try predictions. Let's say
Obama wins. I think the key to the future is to keep
one's eye on the Medicaid issue. I don't think the
Supreme Court ruling on Medicaid is itself important, I
think the governors, once they stop making noise, will
leap on board.
But the public itself doesn't know how much of
the bill's coverage comes from the Medicaid expansion. So
you hear mandate, mandate, mandate but Medicaid is quite
an unpopular program. And the state governors have
financial incentives over time to want to push people on
to the subsidized exchanges.
So I think we'll see a huge tug of war between
governors at the state level; including Democrats I might
add, who would rather spend money on wealthier and more
influential voters; and the federal level, where there is
an incentive to keep people on Medicaid and away from the
subsidized exchanges in too great a number.
And who wins that tug of war, is to me the key
question, I'm not sure. I think what is probably the best
available outcome is for over time if ACA moves to
something like a means tested voucher system where most
people are buying on the exchanges, Zeke has written on
this, I would favor that. But the problem is the way the
exchanges are set up now that would be too expensive.
There is even a part in the bill that says in year 2018 if
so much is being spend on subsidies through the exchanges
it has to be cut.
So I would like to see it evolve into something
where you have catastrophic coverage on the exchanges and
a mandate which is really extremely modest relative to a
lot of current expectations. And then for cheaper
expenditures have something more like a market competition
system. And I wouldn't quite say that's a prediction.
But that's one path through which the law could evolve
into something quite different.
Now say Romney and the Republicans win and also
take the Senate. That's a harder set of predictions but
my gut feeling is they don't actually want to have to
replace, that's a huge embarrassment for them. They
wouldn't know what to do, there are tax credit plans,
maybe in the abstract they make sense, but you spend more
money to achieve kind of the same result and the fact that
you avoid the "M" word sounds great in a campaign --
mandate, "M" word.
(Laughter)
But it doesn't do them that much good in terms
of doling out benefits to people who actually vote and
support them. So my guess is they'll pick on a bunch of
parts, get rid of them and declare victory. And the key
problem for them is they can't just leave the mandate in
place. There's been so much talk about the "M" word, and
I don't know how they'll get rid of the mandate in words
without getting rid of it in practice. I'm personally not
creative enough to figure out how this will be managed.
But my prediction is they are more creative than I am.
(Laughter)
And if Republicans win everything, we'll end up
with more parts of the law than you might think hearing
the rhetoric today. Anyway, I think my time's up.
MR. LEONHARDT: Thank you.
MR. EMANUEL: So let me say a word to pick up
where Tyler said. If you look at the Medicare situation
going forward it really is perfectly economically rational
for every state to adopt the Medicaid program. Because as
Neera said they get 100 percent in the first three years
and it declines to 90 percent of the costs being borne by
the federal government. So state has very little money
going out. Not only does it have little money for getting
more people on Medicaid it actually is going to save money.
MS. TANDEN: Right.
MR. EMANUEL: Because first every state now has
what's called the cost shift. It buys insurance for its
state workers and buried in that insurance is actually
payment for uninsured people. And so that will go down.
In addition, every state has some program for paying for
the uncompensated care that people who are uninsured have.
That will go down when people have insurance.
So from an economic rationality standpoint, and
actually the Council of Economic Advisers analyzed this in
September '09, it makes perfect sense for every state to
go in and adopt the Medicaid. The only reason I can think
of that they wouldn't is ideological. We don't want to do
it, we don't want to expand, you know, you might think
that Texas or Florida will decide that this is, you know,
more a federal program even if it would make sense for the
state from an economic standpoint. And we've seen a lot
of that sort of behavior, where it's not in their interest
but they do it anyway. All those states would -- who --
which want state control of the exchange and yet haven't
invested a nickel in getting the exchange up and running
are not going to have an -- not going to run their own
exchange come next year when they have to go live.
Let me talk about -- as David said -- you know,
I would say a word about cost control. Cost control is
extremely important whether you are a liberal or a
conservative for the following reason. If we can get
health care costs to go moderate and they have moderated
by the way over the last few years then the cost of the
subsidies go down. The cost of Medicaid goes down. The
cost of Medicare -- not goes down, but stays lower as a
portion of the budget, and for private employers obviously
they also have moderated health care costs.
It is a huge advantage to every sector of the
economy if we can actually moderate the health care cost.
Now, one of my -- I've spent a lot of time working with
Peter Orszag, who's somewhere over here --
MS. TANDEN: Over there.
MR. EMANUEL: -- on the bill and trying to get a
lot of this cost control in the bill. And I'd say that we
got a lot of things but one of my big frustrations is we
did not get enough deadlines on cost control. So there's
deadlines on the mandate, you know, the exchanges open
2014, there's deadline expanding Medicaid, there's lots of
other deadlines, but on the cost control we didn't get as
many deadlines as we should. And that is very important.
Because big health systems need to understand
when things are going to change to schedule their
investment and to see that it's real. I think what you're
going to see going forward is a real focus on this cost
control because of its effect on the budgets and its
effect on private employers.
And if you are very interested from a standpoint
of getting more people insured it's also in your interest.
Because the more the costs go up the more precarious this
whole arrangement is. And so I think, again, whatever
your stripe, liberal or conservative, Democrat or
Republican, going forward, that really has to be a top
priority for you because it's the only way the system is
going to be able to keep stable.
MR. LEONHARDT: Neera, you want to jump in?
MS. TANDEN: Can I just make two following
points, Zeke, first on the Medicaid point. There is a
sort of political economy problem on Medicaid, which is
Zeke is absolutely right that states save a lot of money
from their Medicaid expansion because they are --
essentially, they pay a lot of costs right now for
uncompensated care and they -- and they'll get a lot --
that will all be paid for and 90 percent paid for.
The problem for some states is that the
challenge is that that occurs often at the municipal
level, at the city level. So Florida is a perfect
example. Florida at the local level has a number of
programs. Dade -- Miami Dade County pays $170 million or
something like that for uncompensated care through a tax
it pays at the local level. So Florida, overall, will
save but it's not clear -- entirely clear how much that's -
- Governor Scott will save.
So I would say as a good leader of a state you
should care about both the state level costs and your
municipal costs, but it's not entirely clear that every
governor will think that way. And I think that will be a
friction hopefully some -- I know there's some mayors in
this audience that, you know, mayors will recognize that
they are also bearing the brunt of these costs and they
get a big windfall -- and I hate to use the term windfall
but a big windfall from the Medicaid expansion.
On the issue of costs I am -- I agree with Zeke
on the overall issue of how this is a drain on our economy
and we need to get going on costs. The challenge that we
saw through the polarization of the debate, and you know,
Tyler isn't one of these people. But there were a number
of people, I mean, the truth is that for decades it was
Republicans who were leading on cost control issues. And
there are a number of Republican senators who had been
strong advocates of cost control issues; compared
effectiveness research was an area in which there were
Republican senators who had been farther more -- who had
shown greater leadership on that issue.
The challenge with the debate is that it became
so polarized that those same senators made cost control --
basically they called it rationing and hyper polarized the
debate. And my hope actually is that now that we've gone
through the Supreme Court and we've seen -- you know,
we've had final affirmation around this that hopefully
we'll see some of those Republican leaders come back to
the fold and demonstrate that leadership. I will say they
were -- many of them were better than Democrats on this
issue.
But the -- one of the reasons why we didn't get
stronger cost control in the legislation, and I believe
there is strong cost control in the legislation, but maybe
we didn't get stronger cost control is it's only
Democrats. There was -- arguing within ourselves did not
provide enough leverage points because it would have been
really helpful to have Republicans pushing but they walked
away from the whole bill and were really attacking things
like compared effectiveness research as rationing in a way
that made it difficult to make those decisions not easier.
MR. LEONHARDT: Let's spend just a minute on the
politics because you all I think were sort of predicting
that that -- you used the phrase "final affirmation,"
Tyler, you said that the Republicans, if they find
themselves in office aren't going to repeal everything
they're going to -- they say now.
I guess I want to get you to go into a little
more detail on that, because that's not clear to me right.
The history seems to show that what people campaign on
they do, right. And Mitt Romney is campaigning on
repealing Obamacare. He appeared before a sign that
said, "Repeal Obamacare," the day of the Supreme Court
ruling.
MR. COWEN: Repeal and replace, I think it said.
MR. LEONHARDT: Okay. The House is again going
to repeal Obamacare sometime soon, right, they're going to
vote again. So I guess I don't -- let's imagine a world
with a Romney presidency, a Republican House, and a slight
Republican majority in the Senate, which I think if you're
imagining a world with a Romney presidency is probably
most likely, it's certainly entirely plausible. How in
that world does a world in which they don't deliver on the
promises that they made, right, in which the Republicans
come out and they repeal through reconciliation. They
would need only 51 votes through the budget. They get rid
of the Medicaid expansion, they get rid of the subsidies,
and then you're left with the sort of little insurance
market reforms like about 24 year olds being able to stay
on their parent's insurance. How does that --
MR. EMANUEL: Well, first of all it's always a
lot easier to take a symbolic vote that has no
significance and you know will die like the House taking
this vote on repealing. I think that they're not going to
be able to do -- I think Tyler is right, they're going to
do something, they're going to call it repeal but it's not
going to be full repeal because first, there is this
budget problem. That is the health bill actually saves
money over the decade and they're going to -- they would
have to find money to fill that hole and they can't find
that money.
Second, it puts them in the pickle of the
replaced part of it, because a lot of the bill is popular
like the insurance reforms and the keeping kids on until
26 and many other things. And you're going to have to
then have a full set of policies and the Republicans don't
have a policy. We learned all through the debate that
they have lots of things that they would argue about but
it was never a policy. It was never a whole thing that
addressed the problems of access, cost and quality.
The last point I would make is, Romney is going
to need cost control just like everyone else for budgetary
reasons. And I don't think he can throw out the whole
bill because of that. He's going to have to have a
mechanism to keep health care costs down because he's
going to have to get the budget into some more reasonable
balance. And health care; as you know, because you've
written many, many articles on it; is the long-term threat
to the federal budget and it's even a medium-term threat
to the federal budget.
So I just don't see -- I mean, I think Tyler is
right. They'll do something, it will be relatively
modest, they'll call it repeal, but most of the bill is
going to proceed.
MR. LEONHARDT: Tyler.
MR. COWEN: This is what I think they'll do.
They'll take a big axe to the Medicaid sections of the
bill because people who receive Medicaid are not in
general supporters of Republicans. And here's another way
to think about Romney's problem. He wants to get
reelected. You can either govern through --
MR. EMANUEL: He hasn't ever been elected.
(Laughter)
MR. COWEN: Once he gets elected, if he does.
MS. TANDEN: We're living in the theory.
MR. COWEN: If Romney simply governs through
what some people would call the extreme right, he won't be
reelected. It's not that popular a stance. So one
possible strategy for Romney is in the euphoria of having
defeated Obama, if this happens, to immediately do
something to deeply alienate the hard right, establish
popularity with centrist voters, and then slowly over time
as reelection approaches move back towards the right as
campaign contributions matter again.
(Laughter)
MS. TANDEN: Wow.
MR. COWEN: And if you think you're Romney, how
are you actually going to do this. Are you simply going
to take every decision the way that most Republican
members of the House would want you to? I don't think
he's going to do that. There is nothing in his past
record which suggests that and there needs to be some
break, you might as well do a break where you in your own
terms get something for it. So that's my prediction.
MS. TANDEN: So you know the one thing I would
say about this is that I think we should take a lesson
from the recent past, which is every Republican campaign
on repeal and replace, it was the number one issue that
they argued in 2010. You know, but the truth is that the
Republican, House Republicans had two anvils with the Bush
-- with the Obama administration. You know, they had the
government shutdown and they had the debt limit
negotiation.
In both cases they could have used their -- I
mean they had a number of issues. It wasn't just one
issue versus another, but if it was the number one
motivating issue for them they could have used the
government shutdown as an anvil on repeal and replace or
repeal. And the truth is that what was the last issue
been debated. It was actually Planned Parenthood. So it
was not actually Obamacare at the end.
Now, in the debt limit deal there was an issue
about the mandate, et cetera, percolating in last, but it
was actually not repealed. That was I mean they made a
decision, it's always a decision. They made a decision
between -- as between revenues and Obamacare. And that
was probably a rational decision for them, but they did
choose another issue over Obamacare.
And I think -- and I would say just the issue
for Romney is that he is the architect of Obamacare. So
it is a complicated --
(Laughter)
MR. EMANUEL: At least a consultant.
(Laughter)
MS. TANDEN: -- where the world -- it's a
complicated world we live in when he would be the person
to undo it. And what he honestly feels about that about
Obamacare, I mean I'm not trying to be negative. I just
don't really know because a lot of people in Massachusetts
I mean Zeke and I both stayed in Massachusetts, he was
very proud of it.
I mean and people around him argued that he knew
this issue inside and out, in fact, I would say the best
defender of the individual mandate in public life in the
last 5 years has been Mitt Romney. I mean, he's argued it
more effectively than any Democrat. So how that actually
plays out, I can't really determine.
MR. LEONHARDT: He even did it in one of the
Republican debates actually.
MS. TANDEN: In one of the debates recently, it
wasn't like 7 years ago or 5 years ago. It was like
during the last 2 years.
MR. LEONHARDT: Zeke is fan of bets, so I'm
going to -- after this panel, I'm going to design a bet on
the idea of if Romney wins what happens to the bill and
Tyler is going to pick the restaurant.
MS. TANDEN: Zeke only likes bets that he
organizes so he can win, it's not really --
(Laughter)
MR. LEONHARDT: Let's talk for a minute about
the health care system, right. So we had a story on the
front page of the New York Times, a couple of months back.
Looking at the fact that health care cost growth has
already slowed, right. And the article said this is not
mainly because of the bill. The bill appears to play some
modest role as people are trying to organize the health
care system to get ready for the bill.
It's mainly because of the recession; people go
without health care in the recession, the same way they go
without fancy dinners, and the same way they go without
lots of things. But a fair number of experts also think
the health care system itself is beginning to change.
It's beginning to reform itself.
Again not mainly because of the bill yet,
although the bill appears to be playing a positive role
there and there is some debate among health care experts
on this. More optimistic ones think yes, we're already
starting to see -- to use the term of art -- the curve
bend. We're already starting to see a reduction in the
growth of health care costs because people are making
different decisions and more pessimistic ones say no, it's
all the recession.
And when the economy comes back the curve will
unbend right back. I know, Neera, that you are a slightly
more pessimistic about it, right, because we talked about
it.
MS. TANDEN: No, no I'm just -- I'm not -- I'm
just -- I wouldn't be wildly optimistic about what has
happened so far.
MR. LEONHARDT: Yes.
MS. TANDEN: I'm more optimistic about what will
happen in the future on this issue.
MR. LEONHARDT: But so far you don't think
people are changing their behavior, doctors, patients,
hospitals.
MS. TANDEN: No, no, no. I think people are
changing their behavior. I just don't think that we've
been able to -- I don't -- I think most of it is
attributed to the recession, but you know, I think we're
seeing some -- my concern in that article was that it was
just a tad more optimistic than I think we should be as of
this point. I do think that we are seeing -- we're seeing
some movement and positive movement.
And we're seeing that every day and in different
systems. There are -- the big challenges we have really
costly systems that continue and we need to continue to
push that envelope. I just want to emphasize one thing, I
mean, we've had lots of discussions about competitiveness
and American competitiveness over, you know, over the next
several decades.
Zeke is absolutely right. The reason why this
is so critical is that employment in the U.S. is
constrained by health care costs. And it is a continual
drag, and I'd say to put my -- put another pat on this.
You know, if health care costs are constrained, if we can
realign these issues some of the budget wars we've had
between the Ryan budget, whole descriptions of what we
need to do to Medicare as a program.
You know, the most livewire issues will actually
be completely mitigated because if we're actually able to
get Medicare costs under -- or health care costs under
control that will also lower Medicare costs and that will,
you know, that would make the kinds of things that
Republicans and Democrats have argued about, you know, on
the right of voucherizing Medicare in 2020 to -- past 2020
or whatever term we'd like to use, that would make this
unnecessary.
So I do think the real ballgame actually is not
in the mandate or the Medicaid expansion, as policymakers,
the real ballgame is in our ability to lower health care
costs over the next several decades really and use the
Affordable Care Act as it should have been used, as a
leverage point to push this reforms to speed along even
faster.
MR. LEONHARDT: Tyler, you recently wrote a book
about sort of stagnation writ large in the American
economy and society, so I guess the question is how
optimistic are you that we'll escape stagnation in health
care?
MR. COWEN: Here's my pessimistic optimism on
health care.
(Laughter)
I think the economy has recovered. We just
haven't recognized it yet. We haven't faced up to the
fact that this is what recovery looks like and it's not
entirely pretty.
MS. TANDEN: That's pessimistic, right.
MR. COWEN: That's pessimistic, but here's the
quasi-optimistic side of that. If that's your view then
you're very likely to believe we have somewhat broken the
health care cost curve, and that the revenue projections
and budgets still remain overly optimistic, but I actually
tend to think we have seen a turning point and it will
stay with us.
And at some point when we get a much higher rate
of what I call total factor productivity growth and a lot
more innovation then we'll be a lot wealthier and have
broken the health care cost curve. So a 20-year time
horizon, I'm multiply optimistic, but on the health care
cost curve alone I'm optimistic right now, but only for
bad reasons.
(Laughter)
MR. EMANUEL: So first of all, I do think that
the recession has had a big impact. I don't think it's
had 100 percent of -- it's 100 percent explanation. I
mean health care cost growth has gone from 7, 8, 9 percent
--
MS. TANDEN: Yeah.
MR. EMANUEL: -- down to under 4 percent this
past few years. The problem for all of us is 2 years is
just too short to know whether this is a real structural
change or whether this is just a temporary change out of
the recession. The reason I think it's structural and
going forward over the next decade will be structural is
when you go out to hospitals and health systems compared
to what happened in the 1990s, everybody is figuring out
how to do better.
First, everyone is installing electronic health
records which alone won't change, but that combined with
lots of other stuff will make a big change. Second,
they're all working because of the law reducing the
hospital acquired infections, their error rates and lots
of other things that are going to save money. They are
all working to reduce their readmissions because of the
law. They are all anticipating change in payment formulas
and the need to bring their cost structure down. So
they're all figuring out how do we reengineer delivery --
and I could go on and on.
All of those things take time, but over the
course of the next 3 to 5 to 10 years -- so my time
horizon is by 2020, we're going to have a transformed
health care system, where we're going to be delivering
care in different ways. And we're going to structurally
be saving a lot more money over time. And then as Tyler
says we're going to be richer and then, you know, we can
tolerate a little more health care inflation.
And let me say those transformations out there,
they are all going to benefit you. And I know many people
who are well off don't think Obamacare has anything to do
with them and let me say they are wrong. First of all,
all of you are going to have an electronic health record
as a result of this bill by 2020 guaranteed. And it's
going to be interoperable, you'll go to the Aspen Hospital
or your hospital in New York or LA or wherever.
Second, all of you are going to go to safer
hospitals that are going to have less infections and less
errors. And so that you can be a lot sure of the care
you're getting. Third, you're all going to have a
situation where doctors are better at focusing on chronic
illness and better focusing on how to take care of
patients who actually are sick and do a lot more
coordinated care.
All of those are pretty much guaranteed and I
could go on and on, but I think you -- I know you don't
think Obamacare has anything to do with you, but actually
you're going to be big beneficiaries of the bill.
MR. LEONHARDT: It reminds me of a story that
Bob Wachter who is a doctor and an administrator,
University of California, San Francisco told me, he said
when they first started think about error rates around
their cardiac care they went into it with the assumption
of well, we don't have a problem with that. We're UCSF,
we're great. And they looked at it and they had a pretty
big problem with it.
They were UCSF, they win Nobel prizes, they do
ground breaking research, they weren't actually that good
at getting someone who was having a heart attack from the
door to error-free care to -- in the cathlab. And so -- I
mean, it's really fascinating how much quality improvement
there is to be had in this country at all levels.
MS. TANDEN: Right. The one thing I would --
just to bring this back to the court case, you know, we
spent about 5 minutes maybe 10 even talking about what we
think is a central element to the bill, which is lowering
health care costs. I would say something that I was
relatively shocked by with the court case was that the
Supreme Court had four justices who were ruling to throw
out the entire bill because of the Medicaid expansion and
the individual mandate, which we could argue about whether
the entire exchanges are operable based on the individual
mandate or not.
Someone argue -- I mean, its important part, but
you can still have exchanges, but they were willing to
throw out all the work that is in the legislation around
health care costs and they didn't even address it. I mean
they didn't even talk about it in the legislation -- in
the court opinion, they talked about the employer mandate,
they talked about the exchanges, they talked about the
Medicaid expansion and the individual mandate, they didn't
even address that, would -- be willing to throw it all out.
And what I thought from that was it's just, you
know, it was really scary that and one another reason why
I think a lot of policy makers were so concerned that this
issue that should have really been resolved in the --
among policy makers was being litigated by the courts who
are making law not policy.
MR. LEONHARDT: Does it change your --
Department of Health care for 60 seconds -- does it change
your estimation of what happened on some of the other big
issues before the court. Do you now think it's more
unlikely the court gets rid of affirmative action next
year?
MS. TANDEN: Well, you know, obviously there are
a lot of people who think that Justice Roberts was giving
himself a lot of leeway. I mean, you know, I'm -- there
is now leaking out of the Supreme Court so -- which I may,
you know, I went to law school and we worked on the amicus
brief. So I'm shocked that there are conservative --
parts of the conservative wing are now leaking to
reporters about it.
But I'm going to continue to believe, perhaps
falsely, that they will adjudicate law and make decisions
based on interpretations of the Constitution rather than
the politically expedient role.
MR. EMANUEL: Well, I'm not a lawyer, I did
teach at a law school for one semester --
(Laughter)
MR. EMANUEL: -- which gives me authority to
render this stupid opinion. But one of the things you --
I think you saw in the immigration case and in the ACA is
what I'll term -- it's not a great term -- a sort
of "Solomonic approach." So what you got in the decision
on health care reform by Roberts was, you know, on the
Commerce Clause the conservatives are right. On the
Medicaid the conservatives are right and --
MS. TANDEN: Sort of.
MR. EMANUEL: -- then you have -- but the bill
is upheld for the following reason. And I think you got
the so -- the conservatives get some of this and then the,
but the thrust of the bill goes to the President. And the
immigration bill you got pretty much the same thing, you
know, this -- so they'd stop and ask for papers. That
will uphold the rest of it; we're going to affirm federal
control over this area. Again they're sort of trying to
cut the loaf halfway.
But I do think, you know, Roberts clearly is
worried about his legacy, and I think the reason he didn't
want to overturn the law was his court would have looked
like the most politicized court since the Dred Scott
decision. But I think one should not think that his
decision was not politicized.
I think it's heavily politicized; notice it does
restrict the use of the Commerce Clause going forward. It
does restrict how the federal government can incentivize
states to do certain things. And as Neera said, it does
immunize him to some degree going forward as not being the
conservative political judge. So I think it was a very
well-crafted crafty decision.
MR. LEONHARDT: There is not much tort reform in
the bill, right. And that's one of the main -- it's one
of the main complaints. How much, Tyler, could tort
reform help?
MR. COWEN: One percent. Now 1 percent is a
lot, no one should laugh at 1 percent, and I am all for
doing that, but I think it's often overrated, and I think
we'll see it in some form or another within 10 years so -
-. But there's a lot of medical mistakes and I'm not sure
malpractice suits discourage them, but it's not as if
everything is fine and dandy, and is just a lot of, you
know, cry baby patients. Malpractice reform is very
tricky. It's very hard to get right and a lot of people I
think would actually regret it when we end up doing it so.
MR. LEONHARDT: Because there is less
accountability for doctors and hospitals.
MR. COWEN: That's right. I would support it,
but very cautiously, and I would not want to oversell it.
MR. EMANUEL: So let me make two points about
that since I was very active for malpractice reform in the
bill. The first is make no mistake about it, the
President was for malpractice reform. He really wanted
malpractice reform. Prior to running for election he
actually wrote an article in the New England Journal of
Medicine for malpractice --
MS. TANDEN: Yes, with Hillary Clinton.
MR. EMANUEL: -- with Hillary Clinton. For
malpractice reform. He has made clear he's not for
malpractice reform that simply puts a cap on how much you
can sue for. And I think the main reason to do
malpractice reform has nothing to do with the money,
nothing to do with the money. I think Tyler was being a
little generous on the 1 percent. It might be half a
percent, it might be zero percent. It's small money, its
chicken feed as far as cost control.
What it's really important for doctor's
psychological state, because when I go out, and I go to
medical schools, and I go to hospitals and I talk about
health care reform invariably one of the first two
questions is why isn't there any malpractice reform.
Doctors have three or two good excuses before they begin
to focus on what they can do to improve the system.
The first is malpractice. I got to do x, y, and
z that raise the cost or -- because of malpractice. And
the second is those patients, they demand everything.
They want the robot; they want the latest and greatest.
You've got to get rid of those psychological crutches for
doctors to focus on the real thing which is how do they
reengineer care to make it safer, better and higher
quality.
MR. COWEN: I sometimes worry that a lot of our
health care problem is cultural. It's that -- it's not
even so much doctors, it's not even so much incentives in
the system. It's that we're Americans and our instinct is
do more, try everything, never give up, do the latest, do
the greatest, do the most and that that cultural instinct
has enormous benefits, right, enormous benefits. When it
comes to having a cost effective health care system, it's
not so great. Do you buy that at all?
MR. LEONHARDT: It's all true.
(Laughter)
MR. LEONHARDT: It's why we will always spend
more than almost any other country per capita that will
never change.
MS. TANDEN: I know, but I think the issue here
is, is the recession actually impacting this as well,
right? And I mean the question is do -- and it's not
going to be true for everyone, people who can afford it
are always going to ask for more and push for more, that
you're seeing in a wide variety of arenas, people are
recognizing that we live in a time of constraint.
One of the reasons why we have lower costs is
because people are consuming a lot less themselves.
Perhaps there will be some, you know, perhaps there will
be some cultural shifts and also one of the -- another
tragedy of the bill is one of the areas we have a lot of
costs are in end-of-life issues. Those issues were
heavily politicized. Zeke could talk about that since he
was I think "Dr. Death Panel", but you know, there are no
death panels, et cetera. And so I think that's also an
issue where hopefully we can have those conversations
culturally and change things culturally before the
windstorm starts.
(Laughter)
MR. EMANUEL: David, I think one shouldn't put
culture in one category and incentives in a separate
category.
MS. TANDEN: Yeah.
MR. EMANUEL: They intersect and some incentives
reinforce the culture and some incentives undermine this
culture of always more, more and more. And I think we can
get -- create a set of incentives that actually look for
higher value care that is better quality care at lower
prices that will change the culture. There is no reason
we can't get better technologies that are actually cost
savings in health care the way we have in many other
industries.
The problem is there is no incentive to do it
now. Under the future situation where we're paying
doctors and hospitals differently you will have an
incentive to do things that actually can reduce cost but
give you great technology or better than technology,
better medical care at a reduced rate. It's not like
every technology, as I wrote for your paper, is
necessarily better.
We have a lot of technologies which people think
are the latest and greatest and they may be the latest and
greatest technology, but don't add anything to your
quality of your health care. You know the da Vinci robot
for any man about to get prostate surgery, you know, four
armed robot, every hospital advertises it as the latest
and greatest technology. There is no evidence it's better
and there's some evidence it's worse. You know, so yeah
it's great -- it's technology, but it's not such great
technology that it's a real advance.
MR. COWEN: And there is some of this work by
the -- is it -- it's a group in Boston where they're
giving people more information, the idea. There have been
some of these studies where when you really lay out in
detail to people --
MR. EMANUEL: The shared decision making model .
MR. COWEN: Shared decision making, thank you.
MS. TANDEN: Yeah.
MR. COWEN: -- lay out in detail to people the
sort of risks and the benefits and the side effects you
see people choosing less intensive --
MS. TANDEN: Yeah, making --
MR. EMANUEL: So what ends up happening is
almost there are scores of studies like this and they
almost all show the same thing. Give the people
information, 10 to 20 percent of them will say, no, I
don't want that procedure, whether it's a prostrate
procedure or a knee replacement or something else.
And the bill actually has a sleeper clause about
shared decision making, which hasn't been implemented by
the government to try to incentivize us because we knew
there was data and we thought that they were really
important if you made every doctor before he or she did a
surgery or some other procedure actually give to the
patients, you will get 10 or 20 percent of people saying
no, not for me.
MR. LEONHARDT: Let's move to some questions.
We have a couple of microphones circulating, is that right?
What do we have, okay? Let's start right here in the
middle and do we have a second microphone? Okay, great,
so go ahead, why don't you pick someone over there and
right in here.
SPEAKER: Hi, my question -- first of all, I
think it's a false argument to hope that Romney is joking
when he says he's going to repeal the health care bill.
The Republicans, when they say things they're pretty
serious about it. How do we convince people like this
crowd or my friends at home that they need the health care
bill and it is good for them even though they -- even
though they have insurance that it is good for them and
their children?
MR. EMANUEL: So let me. I gave you several
things that was going to be better for them if the bill
gets passed. The electronic health record, say for
hospitals higher quality care. Here's -- I mean there
are kids the -- keeping them on their plan till 26, which
is now part of the bill, and you know, while many
insurance companies have said they'll keep it who knows
how long they would keep it. But also that security that
you have a mechanism, separate from your employer to get
coverage at a reasonable rate in the exchange, I think, is
a really important guarantee whatever your pre-existing
condition.
Let me tell you an interesting fact that most
people don't know; 10 percent of the uninsured make over
400 percent of the federal poverty line. They are well
off and could buy insurance. And yet they don't seem to
have it. Most of those people it's not because they don't
want insurance. It's because they or someone in their
family has a preexisting condition and they can't get it
at any price. This solves that problem for them.
MS. TANDEN: And you know, I would also say
there are a number of ways in which the law also
emphasizes preventive benefits, preventive benefits in
Medicare, the preventive benefits that you get just in the
regular health care system that doctors have to provide
you. And there is a prevention trust fund that is a
little bit vulnerable to attack. But there is, basically,
you know, we do have a broad problem in our system which
we've referenced a little bit. But we have an acute care
system, not a health care system. We basically pay for
every time you are sick. We don't pay for keeping people
well.
There are a number of ways that you try to --
the bill incentivizes keeping people healthy. Both in the
-- reimbursements increase for preventive benefits in
Medicare. And there are also ways in which it's trying to
get information out to doctors about what the best
prevention methods are. So that's another way in which --
the bill does try to actually improve the entire health
care system by ensuring that it moves away from the acute
care model.
MR. LEONHARDT: Isn't there some instant polling
that shows the bill is already more popular?
MS. TANDEN: Yes. Yeah, also and Obama's
numbers have flipped. But just temporary.
MR. LEONHARDT: Sir.
SPEAKER: Can you comment on -- can you comment
on the potential impact on medical education? I have a
friend who is a dean of a medical school and says, we are
still teaching doctors as if from 1900 -- from textbooks
from 1900. Right?
MR. EMANUEL: Yeah. Well, I have been convinced
in my life that nothing moves more slowly than medical
education.
MS. TANDEN: Yes.
MR. EMANUEL: And it is true that most medical
schools have not adapted -- I wrote recently an editorial
in one of the medical magazines that we should cut medical
training by 30 percent. We could get rid of tons of
medical school education and not harm the quality of the
doctors we are producing. A lot of it is completely
unnecessary. It's anachronistic and even worse, in my
opinion, there are lots of things necessary for them to
understand about the financing of medicine, about how you
measure quality, how you can reengineer for quality that
aren't being taught. I think there's going to become
increasing pressure on medical schools, as the decade goes
on, to really make a big break and to really do something
innovative and novel. And Lord knows -- I think they are
going to have to do it.
There are also some financial pressures that are
likely to come to bear on them for not the medical school
training, but the training afterwards because that's
likely to be cut in the next few years. And that will
focus the mind.
MS. TANDEN: One thing I -- one issue on this is
-- and this is a broader trend that -- it's not just for
medical school but medical school is kind of the crucible
by which you can see it, which is, you know, the entire
manner in which people are taught in medical school really
is for the idea of a solo practitioner making all
decisions by themselves.
And as we see technology permeate other areas
and other parts of the economy what we are seeing is --
one of the reasons we are hopeful about progress is that
what is making, and actually getting better value out of
the system, the health care system, is that team based
approaches to medicine are incredibly effective. They
produce value and they make doctors actually happier. So
one of the -- that's -- that needs to permeate medical
education. They need to change the culture, as David was
referencing.
But also, I think one of the ways that that
happen is that doctors actually like to be in these
approaches. They like to -- they like salary, over being
a solo practitioner. There are ways the culture is
changing in a way that they like and they are going to
have to have a feedback loop to their schools when they
are alumni to actually shift that. And I think that is a -
- that will happen. It would be great if medical schools
would adapt early instead of be dragged to it, but that is
an area that's important.
MR. LEONHARDT: It's interesting to look at and
let me see some hands again.
SPEAKER: We have Dokine Peter (phonetic).
MR. LEONHARDT: Go over here for one and then we
will come up here for number two. It's interesting when
you think about how health care is changing a lot of this
data collection --
MS. TANDEN: Yeah.
MR. LEONHARDT: Patients don't use at all.
MS. TANDEN: Yeah. This is a huge issue.
MR. LEONHARDT: The way in which it matters is
doctors use it. Doctors hate the idea. Wait a second, my
hospital's ranked seventh in error rates even if patients
aren't actually going to checking and choosing based on it.
MS. TANDEN: And just quickly on that. I mean
electronic medical records are great but the way they
increase value is they actually can provide you more up to
minute information about what's wrong with you and what
the best way to care for you is which really informs
hopefully consumers but mostly doctors in what to do about
it.
MR. LEONHARDT: Guest questioner of Peter Orszag.
(Laughter)
MR. ORSZAG: Thank you. Actually before I ask
my question, just quickly, one of the things from one of
the panels yesterday -- Betsy Nabel who runs Brigham and
Women's in Massachusetts, indication of the changes that
are occurring when asked what share of payments do you --
in your strategic planning, in your internal planning,
what share of payments within the next 3 years do you
think will not be fee-for-service, which is at the heart
of the change.
MS. TANDEN: Yeah, the challenge.
MR. ORSZAG: She said 100 percent. Within 3
years they are assuming all of their payments are some
sort of risk payment to the extent that that is being
replicated at hospitals across the country, a huge deal.
MS. TANDEN: Yes. And Massachusetts is very
expensive.
MR. ORSZAG: Now my question. In this -- let's
speculate about what will happen if a Romney victory and
then a Republican sweep. Because it strikes me, you can't
analyze what will happen in a repeal scenario in
reconciliation without taking into account other things
that will have to happen in reconciliation. And I
suspect, this is a just a guess, but I suspect the most
attractive thing that will be part -- for those newly
elected Republicans is block granting Medicaid.
They have to do something big. Block granting
Medicaid is big. You can do it in a way in which you put
upfront payments at a higher rate to start with and then
you flat line them so that it looks great for the federal
government, and governors will, facing a $50 billion
aggregate deficit at the state level, perhaps find that
attractive.
So the question is how do you evaluate -- that's
a -- all the -- the Supreme Court decision then becomes
kind of irrelevant because Medicaid is fundamentally
different, at least along that dimension. Could you
evaluate whether you think I'm crazy? Well, at least
along this dimension. And secondly, if that is the -- if
that is actually, ultimately done what impact it has.
MR. LEONHARDT: Tyler, you go for that.
MR. COWEN: This is exactly what I think will
happen and furthermore if Romney does not win, I think,
there's a very good chance it will happen over the next 10
years anyway under the U.S. system of government. So I
think the political tendency is that all people win all
battles. And as budgets get tighter, funds will be
reallocated from Medicaid to Medicare often in ways which
are not value enhancing. And my 5-word theory of American
politics like all people always win is a pretty good
theory.
MS. TANDEN: Well, I mean --
MR. COWEN: And I wouldn't focus too much on
Romney though I think that is what exactly what they would
do.
MS. TANDEN: But as you know, the challenge with
Medicaid is that the biggest growth in Medicaid -- what
costs the most in Medicaid is long term care for seniors.
So, you know, the challenge that exists in Medicaid is
that when -- actually, you know, when people realize that
the only thing that helps them deal with those long term
care services comes through Medicaid not thorough
Medicare, especially --
MR. COWEN: That's because (inaudible).
MS. TANDEN: Yeah, I mean it's possible. I
guess, you know, that would be an interesting world we
live in in which we kept the Affordable Care Act and
denied for middle income Americans, working Americans --
and denied coverage to poor children, pregnant mothers,
some families -- I mean, I guess we could live in that
world, but it would be a hard world to live in.
MR. EMANUEL: I think Peter, though, you know,
if that eventuality comes to pass and those of us who
really care about people getting coverage and not wanting
to see states take the block grant and then screw their
population, their poor population especially, what you
would have to focus on is what are the metrics that they
would have to comply with to continue on the program and
what quality and access metrics.
So I think Democrats will need a strategy for
that approach. And I agree -- I mean I think the one
thing which is sort of worrisome about that is fiscally
for the federal government, it will look great. But it
transfers the risk down to the states. And I think, you
know, we are going to see a lot more states either tether
on insolvency or actually go belly up and it will make
Stockton (phonetic) look like a, you know, just a small
end of the wedge.
SPEAKER: Well, first of all, with respect to
Justice Roberts, I think it's worth noting that I don't
think Justice Roberts really bought the taxing clause
argument. I think he was actually extremely conservative
in his opinion. And he was simply trying to exercise
judicial restraint and transfer the power to pass this
kind of legislation to the Congress and he hung his coat
on it.
Moving on to the -- to the -- and he quotes
Justice Holmes I think in the opinion to that effect.
SPEAKER: Yeah.
MS. TANDEN: Yeah.
SPEAKER: I am surprised that we are celebrating
a decrease in the rate of increase in medical cost. In
other words, I think it was said that the rate of increase
in medical cost is down to 4 percent, but we have a 1.9
percent GDP which means that medical cost is still
increasing faster than GDP.
And my question is where do you think we get to
in 10 years time, medical costs as a percentage of GDP,
and how do we get to a 11 or 12 percent like some of our
neighbors are so that we can be competitive.
MR. LEONHARDT: I'm actually going to take a
very quick crack at that --
MS. TANDEN: Okay.
MR. LEONHARDT: Just philosophically, I think
it's important to keep in mind, and you didn't say
otherwise but it's important to keep in mind, health care
growing as a sector of the economy over time is not only
okay, it is good. Think about a rich society, right?
Think about a rich household. You have got two cars. You
have got four TVs. You have got a VCR and then you got an
extra $100. What do you want o spend it on? Do you want
to buy another VCR or do you want to spend it on your
health? Right. And that is why over time for rich
societies health care grows as a share of GDP and it's
natural for it to grow as GDP, right?
MS. TANDEN: (Inaudible).
MR. LEONHARDT: But now to your question which
is how high do we get and can we ever get -- I mean we are
so much higher than any other society.
MR. COWEN: Steady state 40 percent will love
it. The other stuff doesn't make me happier. And someday
the stuff will actually start to work. I mean that's the
miracle.
MR. EMANUEL: So -- 40 percent I'm not sure
where someday is.
MR. LEONHARDT: Where are we now, 17?
MR. EMANUEL: Eighteen.
MR. LEONHARDT: And other rich countries are at
12?
MS. TANDEN: Right. The most --
MR. EMANUEL: So, when we talk about cost
control, sometimes I slip and say cost savings. But it's
not -- we are not going down. We are not going from $2.8
trillion dollars, which is what we will spend in 2012 down
to $2 trillion. The question is how slow does it go up to
$3.5 trillion and $4 trillion. And that is a very
important number because as the GDP grows, as David said,
we are going to spend more. There's very good correlation
across all rich countries that that happens. But the
issue is how slow can we get it.
For a brief shining 5-year period, 1993 to 1998,
we actually got relatively steady state keeping it about
18 percent. My guess, and this is just pretty crude -- we
will get to 20, probably 22 percent over 10, 12 years.
And then, you know, I think we will probably flatten it
out. Assuming we get, and Peter prefaced what he said,
assuming we get consistent changes in payment by the end
of the decade.
MS. TANDEN: Can I just reference the Roberts --
and you know, what I thought was fascinating about the
Robert's opinion writ large is that, you know, on the
Commerce Clause where we have, you know, a lot of
jurisprudence that essentially argues that since the New
Deal, the Supreme Court is not going to second guess large
scale economic decisions by the Congress.
You know, there is like no judicial deference to
Congress in the Commerce Clause jurisprudence. I mean you
read through the case; his attitude towards Congressional
action is one of -- I wouldn't -- contempt is too strong a
language, but it is with deep skepticism -- a skepticism
that I would argue no majority opinion has had towards --
against anything that touches economic activity in 30 --
in 100 years or close to 100 years.
So and that is you are absolutely right that he -
- his language around the taxing clause is essentially
like it could be constitutional, so I'm going to find it
constitutional. I am just saying, that was not the
attitude towards the Commerce Clause. Certainly, he
didn't have the attitude it could be constitutional, so I
am going to find it constitutional.
And again the dissents -- the four conservative
dissenters did call him on that. And I think on that one
issue they were right. But you know, my view is that it
was an oddity for him to create a new -- essentially a new
precedent that, you know, if you read through the opinion
it does not have a lot of precedence behind it, a new
precedent that limits activity under the Commerce Clause.
MR. EMANUEL: Let me state this adds one other
element to why this election is going to be a monumental --
MS. TANDEN: Right.
MR. EMANUEL: -- election, maybe, one of the
most important in 100 to 150 years, which is you are going
to have probably at least two justices retire and maybe
three. And whoever is president is going to appoint them.
MS. TANDEN: Yes.
MR. EMANUEL: So, in addition to all the other
stuff that is going on, you know, implementation of Dodd–
Frank, implementation of the health care bill, all the
other things that are going on --
MS. TANDEN: You are right.
MR. EMANUEL: The Supreme Court is going to be
reshaped.
MR. LEONHARDT: There should be a panel next
year about why Supreme Court justices don't retire early
and aren't more strategic about it because --
MS. TANDEN: It is really -- but there is an
argument about --
MR. LEONHARDT: If you think about Supreme Court
justices enormous risks with their own beliefs.
MS. TANDEN: Yeah, absolutely. I think it's
power.
SPEAKER: I heard that the number of applicants
applying to medical school is decreasing significantly and
that the quality of those applicants is also decreasing.
Now if that's accurate -- I heard it from a panel, and if
that is accurate how is the system going to handle it with
more and more people that were going into the emergency
room with a mandate now having insurance needing primary
care physicians, and they are not paying enough, how is
the system going to handle it?
MR. EMANUEL: So there are two parts to your
question. One is, have the applicants to the medical
schools gone down? To the best of my knowledge, it's not
true. Actually, I think they've gone up because of the
recession and people going away from business school. So
I don't think that's actually accurate.
The second thing is there is a question about
workforce and if we add in 30 million people to the system
can we actually handle it. And the short answer is
absolutely. And let me give you a few reasons. One,
Neera actually pointed to, which is increasing working on
teams where there are lots of things that I do as a doctor
that I don't have to do that a nurse could do or even a
health aide who doesn't even have medical training could
do. We are going to see increasing use of that because it
makes no sense for me to be doing a lot of those things.
The second piece of information I would suggest
to you is a lot of what we do, repeat visits. So I am an
oncologist. When my breast cancer patients come back
right after we finish chemotherapy, they come back. I
schedule them for 3 months for the first year and then 6
months.
Where did 3 months come from? It's hocus pocus.
No one has any data it makes any difference and there's
lots of reasons that it shouldn't make a difference. And
so you are going to see a lot of change in how we handle
that.
And the last thing I would say is if you look at
Massachusetts where they brought 500,000 people into their
state, no change in waiting times at primary care doctors.
No change in waiting times at cardiologists, no change in
waiting times at obstetricians. That's not data from left
wing nuts. That's data from the Massachusetts medical
society.
MR. LEONHARDT: They might be left wing nuts.
(Laughter)
MR. EMANUEL: I know that.
MR. LEONHARDT: We will take one last question.
Sir, you have had your hand up almost the whole time.
MR. STEIN: I'm Norman Stein (phonetic) from the
American Enterprise Institute. I have a question mostly
for Tyler and it follows a bit on what Peter said.
Imagine that Republicans take the House, Senate and the
White House and pass what Paul Ryan has called the mother
of all reconciliation bills.
That means that we make the Bush tax cuts
permanent, cut the top rate to 25%, cut Medicaid by 30
percent and send it back as a block grant to the states.
It would cut out the tax on the health care mandate and
also probably cut out funding for much of the rest of it
along with the whole series of other changes.
What do you think the odds are that Mitt Romney
would veto that bill?
MS. TANDEN: Great question.
MR. LEONHARDT: You are the conservative.
MR. COWEN: I think he is skilful enough not to
get into that position in the first place. And there are
enough Republicans who want to be reelected that they
would, in a quiet way, support Romney. And I think a lot
of what you mentioned is what would happen.
I don't think it would be a 25 percent rate.
That sounds too low. But the Bush tax cuts would be
continued and made permanent. But I think there needs to
be some kind of health care policy put on the table and it
would be radically relabeled. But cost control will be
kept. Cuts to Medicare or potential cuts to Medicare will
be done away with.
Medicare will be firmed up. That will be sold
to Republican and elderly voters. But parts on the right
will take a real hit. And I don't think the full blown
Ryan plan will ever happen.
MS. TANDEN: I would just say I have been
waiting for the silent majority of Republicans for a
little while here over the last 3 years. And it's been
difficult to see them on these policy issues. So I hope
you are right.
MR. LEONHARDT: It sounds like Norman's on my
side of the bet.
Thank you all.
SPEAKER: Thank you.
(Applause)
* * * * *
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