Shownotes Transcript
This Washington Post Live podcast is sponsored by Oscar Health. I'm Paige Winfield Cunningham, a reporter covering health policy for The Washington Post. And welcome to Washington Post Live. I recently spoke with Representative Jake Auchincloss about Medicaid, the Affordable Care Act, and what will happen to these programs if the One Big Beautiful Bill Act passes.
We also talked about Maha, the Make America Healthy Again movement you've heard so much about. Here's what I have seen from Maha so far. They issued a report that said that there was no benefit whatsoever to ear tube or tonsillectomy surgeries, which is radically out of step with scientific consensus. I mean, that's just that's quackery.
and is really going to have a detrimental impact. Then I took a deeper dive with Larry Levitt and Jean Lambrew about the drivers of health care costs in America and ways to make the U.S. system more affordable.
So let's talk about what's hot on the Hill first. And of course, it's this enormous bill that House and Senate Republicans are trying to pass ahead of July 4th next week. And President Trump has said this is arguably the most significant piece of legislation that will ever be signed in the history of our country. You, however, said it's the worst bill you have voted on in your time in Congress. Can you tell us why you said that?
It explodes the national debt. It cuts health care for 10 million Americans. And it is going to lead to more mass shootings. They tucked in a $1.5 billion tax credit for the purchasing of silencers for pistols.
which will make mass shootings far more deadly because the victims won't be able to distinguish the origin of the shots when they're fired. This isn't academic. Here in the United States of America, mass shootings are a fact of life, as J.D. Vance has attested. And now it's going to make it easier for would-be gunmen to silence their weapon systems.
Let's talk about the bill's changes to Medicaid and the Affordable Care Act. I know this has gotten a lot of attention and for good reason, because it would cause millions of people to lose their coverage. And right now, as we speak, the Senate is trying to figure out what they're going to do on that and how they're going to get all of their members on board. Are you...
Concern, where do you think all of this is going to go as we look at the next couple of days? And we know that Democrats aren't going to vote for this legislation. But how do you look at this whole endeavor from your perch?
I think congressional Republicans are going to huff and puff and then Donald Trump's going to blow them down. They always claim they have concerns and they're going to stand up on this or that issue. And then they fold. They've always folded for the last decade. This bill is going to pass and it's going to be bad for Medicaid. And the reason it's going to be bad for Medicaid is really two words, uncompensated care.
We still have in place EMTALA, the 1980s law that says that anybody who comes to an emergency room gets medical care via the emergency room site of care, which we know to be much more expensive and for a lot of different conditions, behavioral health, for example, much less suitable as a site of care. So what's going to happen is they're going to impose this new bureaucracy, paperwork requirements that
A bunch of individuals are going to fail to meet, as we see in Georgia and Arkansas, not because they're not eligible, but just because it's a whole new paperwork bureaucracy that they're going to fall through the cracks of. They're then going to get less care for chronic conditions. They are then going to go to emergency rooms when those chronic conditions crystallize into an acute condition. And they're going to get much more expensive care that individuals who have employer-sponsored health insurance
or Medicaid are going to be forced to cross-subsidize and everyone's health premiums are going to go up. But it sounds like you think that Republicans are going to actually be able to pass this bill. And I have to say, I'm a little skeptical. I don't know if you probably recall back in 2017 during Trump's first term when they tried to pass Obamacare repeal and all of that collapsed at the last minute. So what makes you think that they're going to be able to coalesce around something with even bigger health care cuts this time around?
The ACA repeal was a standalone measure. If these Medicaid cuts were standalone, they would have no chance. But they're being paired with tax cuts for the rich. And the Republicans just can't help themselves. They just adore giving tax cuts to the rich. And they will pass the Medicaid cuts as part of it. They won't say no to the dear leader. They'll make some marginal changes, but they're not saying they're not saying no to Donald Trump. I just I've been here too long to believe it.
One of the things that I know I've written about is the effect on rural hospitals. And I know a lot of Republicans in Congress are getting a lot of pushback from these hospitals that would see their Medicaid reimbursements go down. And so it's this real tension, of course, that Republicans are feeling. How do you talk to your colleagues on the other side of the aisle in the House about this disconnect? And what do they say?
I spent 27 hours in a political brawl in the Energy and Commerce Committee having exactly this debate about uncompensated care, about federally qualified community health centers, about the failures of these paperwork requirements in Georgia and Arkansas. I know what the Republican talking points and rejoinders are. It is illegal immigration.
I promise you that is going to be how they campaign on this issue. They're going to say that what they are doing is preventing Medicaid from offering health insurance to illegal immigrants. And they're going to hope that voters don't notice that actually what they're doing is cutting at-home care for seniors or primary care visits for children. But voters are going to notice that. More than half of voters have a direct familial experience with Medicaid. Two-thirds of voters have a favorable opinion of Medicaid.
And this attempt to change the subject from health care to immigration isn't going to scrub. I think that these actions have surprised a lot of people because, you know, we have seen a large increase in the Medicaid enrollment in the last couple of years. And many of these new enrollees are in red states, in red districts.
And, you know, what's what's interesting about it, too, is that Republicans in recent elections have seen their support grow among voters who benefit from Medicaid. And Democrats have struggled with this population of people more than they had previously. What do you make of that? And what can Democrats do to shore up this voting base again?
Well, you're plugging into a much bigger conversation about Democrats' issues with cultural condescension and our conveyance of contempt for a lot of working class voters' concerns, both economic and cultural. But to focus specifically on health care, I'm glad you raised this question about Medicaid's resonance with so many Americans, because to me, this is the go forward opportunity for my party. Yes, we have to fight against these Medicaid cuts.
But in 26 and 28, I don't want to see us become the party of...
we're defending the health care status quo or we're simply focused on extending ACA premium tax credits. I want us to have big, bold health care ideas. And those big, bold health care ideas, I think, should have two themes to them. One, that the critical question for Americans is no longer coverage, it's cost. It is the cost of care, which if you have coverage, but your out-of-pocket is $18,000 for a family of four, that doesn't really feel like insurance anymore.
that feels like you're paying a premium and you're paying again when you actually need the care.
And number two is people like Medicaid. And we shouldn't be abashed about defending Medicaid. We should go on offense. We should actually say Medicaid is going to become the basis in democratic states of social security for kids. And I think this is the opportunity for Democrats, for us to turn Medicaid into social security for children by combining an expansion of community health centers with guaranteed catastrophic medical care for all children.
in a state with the use of health savings accounts for children at birth that the state helps to subsidize for any health, education or wellness purposes. And I'm happy to dig into more, but we actually have an opportunity here to not just defend the status quo of Medicaid, but to make it the basis for big, bold ideas. Yeah, I mean, I want to talk a little bit more about that idea, you know, because
Republicans, for what they're trying to do, they're insisting that they're not cutting Medicaid benefits. And the president seems to recognize at least that you can't appear as though you're cutting benefits because, as you say, this is a popular program and many people are enrolled in it. And so I'm wondering if you see any areas for bipartisan compromise on that goal of cutting costs.
and making that experience of getting health care easier and more affordable for people? Not through this bill, because this bill will be partisan. But in general, I haven't met a policymaker in Washington who likes waste, fraud and abuse, right? And of course, there's waste, fraud and abuse in Medicaid and Medicare. It's frankly not probably as big as in the private health insurers. But of course, it happens. And we need to have robust inspectors general and we need to have
cutting edge technology to discern where that fraud or abuse is happening. And yes, if there are pandemic era programs that have gotten bloated and need to be tightened, yeah, we should take that on. But in general,
some of the best places to go after fraud and abuse like part c where united health is under criminal investigation for its upcoding for example the republicans are leaving untouched whereas what they are going after is actually relatively lean uh administrative overhead in medicaid programs at the state level so it's just their rhetoric and their actions aren't jiving in the long run there is absolutely i think areas that that we could work on this so for example
I think RFK is probably the worst public health official in the history of the United States. I guess he just came to Congress yesterday and issued an abysmal performance of quackery and conspiracy. But there is one thing that I agree with him on, which is he likes community health centers and I like community health centers. And he is very skeptical of junk food and sugary beverages being marketed to kids. And I am as well.
So what happens if we said, let's levy a tax on the advertising of sugary beverages and junk food to children, which we know accounts for half to two thirds of the empty calories that they consume.
and route all of those revenues directly through Section 330 grants to triple the reach of community health centers so that every single kid under the age of 18 and under 300% federal poverty level has access to heavily reduced cost, not just primary care, but behavioral care, diagnostics, opticians, diagnostics, the full suite. That's something that we can work on, I think, at least now.
you know, at least conceptually, there is agreement there. I'm glad you mentioned RFK because I did want to ask you about him and also the larger Make America Healthy Again movement. And, you know, one of the ways to think about, I think one of their core messages is that,
we have these underlying problems with nutrition, with exercise that need to be addressed versus just treating the illness. And I'm wondering if you can share, how are you looking at the Maha movement? How do you feel about it? And do you think there's anything of value there?
So, first of all, the point that childhood obesity is a problem, that chronic disease is a problem, that the link between the gut and the brain is important, that what we eat is important, that the quality of our food is not high enough. I mean, Michelle Obama was talking about this 15 years ago. It is absolutely true. I would be strongly in favor of robust nutrition.
action on this front. I just described, you know, taxing the advertising of sugary beverages to kids or even the consumption of sugary beverages through a sales tax, so long as those funds are routed to expanding direct primary care access for children as part of a social security for kids mantle. But I just haven't seen that from Maha. Here's what I have seen from Maha so far. They issued a report
that said that there was no benefit whatsoever to ear tube or tonsillectomy surgeries, which is radically out of step with scientific consensus. Has there been some over-medicalization of those procedures? Perhaps. But no serious ENT physician would ever say there's never a scenario where you should do an ear tube procedure for a kid with sleep apnea or tonsillectomy for a kid with
Sleep apnea or an ear tube for kids with chronic ear infections. I mean, that's just, that's quackery.
and is really going to have a detrimental impact. I've seen them make up citations in this report that actually link to studies that said the exact opposite. I've seen them install a number of officials who have gross conflicts of interest, including Cali Means, who is running a functionally a money laundering machine for HSAs, TruMed, on the side while he's a White House advisor changing benefits design to help his company. So
And I haven't even gotten into vaccines, which has been well covered already. But suffice to say, he's just turbocharging the conspiracy that has defined the last 20 years. So this guy is a uniquely dangerous, incompetent and corrupt individual.
I think we're stuck with him for the time being. And we're going to have to try to insulate HHS scientists from from Office of HHS secretary. And if they want to work on community health centers, we can work on community health centers. You mentioned that he visited the Hill yesterday and spoke to members of Congress. Can you tell us more about that and what role he's playing in this whole discussion about the big, beautiful bill?
I don't think anybody's consulting him on the big, beautiful bill. Let's be real here. Like he has no idea how Medicare and Medicaid work. We saw that with his confirmation hearings where he literally doesn't know the difference between the two of them on the Hill yesterday. He incorrectly said, for example, that there was a drug pricing measure in that big, beautiful bill that is not in there. The fix from nine to 13 pill penalty, like that's just false. He asserted that it was in the bill. So he doesn't know what's going on with that bill. I don't think
Republicans in Congress, frankly, take him all that seriously on this bill. What he is doing is
gutting ACIP, the Advisory Committee on Immunization Practices, and inserting a crew of people who will give a majority to undercut immunization practices. His next step, Paige, is going to be to go after the Vaccine Injury Compensation Program by trying to add autism to the table of injuries and thereby making it almost impossible to commercialize, distribute, develop vaccines. And we're going to see more outbreaks of contagious diseases if he gets away with it.
You know, but we I do want to ask you, though, about how Republicans should be talking about this issue of trust in public health agencies and in the medical establishment, because we've seen a real erosion here. And I think that's one reason that RFK has such a strong base of support, especially among these Maha moms that we've written about here at The Post. And, you know,
There is a need to try to restore people's trust and confidence in the CDC, in their doctors. How should Democrats be talking about that? And how can they start to kind of rebuild that trust, especially among people who have just been really disillusioned during COVID and feel as though they've been lied to?
So if Secretary Kennedy had been made secretary of agriculture instead and was really let loose on big food, I think there was a lot of areas we could have worked with him on. Because again, the big food companies, the marketing to young kids, the sugary beverages, the highly processed foods, these are leading to chronic diseases. They're leading to childhood obesity. As Secretary Kennedy said, there's no Republican kids or Democratic kids. There's our children as a nation. And they're being failed.
by our food system. I agree with that and I won't rehash it, but willing to work on that issue with him by pairing taxes on some of that food with direct access to primary care and specialty care for children. I think we can build bipartisan support for that. But going after vaccines for measles, that is going to inspire massive pushback and it's not going to build public trust.
I think where Democrats have to do work on building public trust after COVID, because that's really, I think, the crystallization point for a lot of this, is on the school closures. The school closures were a catastrophe. Dr. Ashish Jha, who went on to become Biden's COVID coordinator,
said in May of 2020, May of 2020, that's one month after the outbreak, that the schools could and should safely reopen. Well, in blue states and blue cities, it took another year. I know that because it was my day one issue was reopening the schools when I took office. And that was a terrible failure. And it's
It has led to incredibly profound academic and socio-emotional deficits for American children. About half of American students now are behind grade level on reading and writing. Most ninth graders are entering with more like a sixth grade preparation level. That's unacceptable. And we got to fix it. We got to surge one-on-one high dosage tutoring to our schools. We got to build a thousand trade schools.
Are we going to take on the social media platforms that made hundreds of billions of dollars during the pandemic, dragging our kids down digital rabbit holes? We've got a lot of work to do to build back trust after the school closures.
We're almost out of time, but I do want to ask you about your home state of Massachusetts, which for a long time has really stood out as one of the healthiest states in the country. It has the highest childhood vaccination rate, highest rate of health insurance coverage, lowest infant mortality, fewest premature avoidable deaths. What can your home state teach the rest of the country? Universal coverage is a critical element of this.
But I think we're our home state, my home. And I'm proud of the fact that we were avatars and forerunners of Obamacare, excuse me, in many respects. We're also leading on behavioral health management and integration of social services and mental health care with first responders. Where my state now needs to lead next is on cost because the health insurance premiums in Massachusetts are huge.
suffocating employers, families, and municipalities. And this is the next great frontier is how do we tackle costs? I think there's an opportunity for us to take our 1115 waiver and really go even more into the role of Medicaid as potentially a single payer for catastrophic medical care, paired with divorcing primary care from insurance altogether. Primary care really should never have gotten intertwined in this insurance
in this insurance system because it's not a rare, unpredictable and expensive event. It is more like a recurring, relatively inexpensive part of health and wellness. And we should directly subsidize the providers of primary care and directly support families' access to primary care without making them go through multiple layers of insurance bureaucracy. And that will lower costs as well as allow our Medicaid system to focus on the catastrophic medical care element.
Well, lots to explore there in future conversations. This has been a fascinating discussion. Congressman Jake Auchin-Kloss, thank you so much for joining us. Thanks for having me on. Please stay with us. I'll be joined by Larry Levitt and Jean Lambrou right after this.
Hi, I'm Kathleen Koch, a bestselling author and longtime Washington correspondent. Most Americans today get their health insurance through their employer, Medicare or Medicaid. About 14% rely on the individual insurance market, but some believe that market could serve more people and do a better job. Here with me to explain is Mark Bertolini. He is CEO of Oscar Health. Mark, thanks so much for joining me. Thank you for inviting me, Kathleen.
Mark, many look at the current health care system here in the U.S. and I believe it could, shall we say, use some out-and-take name. Why do you think the individual insurance market holds such promise? The individual market offers employees and consumers the ability to choose their own product, choose their own network, choose their own coverage at a cost that's affordable and competitive.
The market is very competitive today secondly the system we have today was designed eighty years ago. I'm in the government put on wage and price controls after world war two. And the system is evolved where the consumer is actually isolated from the purchase decision the employer makes that choice for them and secondly they can't use their money in a way that best suits their own particular needs.
Well, I know about a quarter of those enrolled in individual insurance are small business owners. I know they're not the only ones enrolled, but why is the individual market such a good fit for them?
It's a good fit for any insured employer that provides full insurance coverage for their employees, in large part because they have to choose large networks to cover all their employee needs. And they have to use one or two plan designs because they can't have infinite variety at a reasonable cost. Both of those cost more. Large networks cost more because you can't focus market share on the providers. In the individual market, we have networks for each community.
each state. 75% of all providers in the United States are in a network in the individual market. So the chances that you could find your own network is very possible. You can definitely pick your own products because we all have our own version of the products and they're more competitive. The last four years, the trend rate in health insurance in the individual market has been 3.5% less than CPI.
which has been the definition of a reformed health care system. Talk to me about the others who are enrolled in this. And in general, how is this system better than the traditional employer insurance, other than what you just explained there?
Yeah, I think it's better because employees can see what they're buying. I can find my network, my doctor, my hospital, which when people change situations, employers are in and out of employment. They have to find another plan and another network. Maybe they can find their own network. So they can't keep their doctor in their hospital. A plan, a promise of the original ACA marketplace. Secondly, I can find a product that suits me with an employer. I'm paying 15 percent of premium on average.
For a product that's for everybody, which is often more costly because of the sick people in the group, because they underwrite the group. In the individual market, they don't have to do that for me. I can pick my product. I can pick it on the basis of what I foresee. So I get my own network, my doctor and my hospital. I get my own product that fits my family's needs at a very competitive cost last year.
We had an employer switch from the middle market, so between $1,000 and $5,000, that saved 26% to 30% on their healthcare costs by moving to an individual product.
But it's good for individuals too, correct? Gig workers, others? Yes. Gig workers are perfect for this. They're people who have multiple employers. We can create hour banks. A little bit of each hour goes into a bank for them to be able to buy their insurance every month from the individual exchange. Again, their product, their network at their price point. Last year, Americans borrowed $74.9 billion.
for two out of five Americans to pay for their out-of-pocket costs. With an individual product on a defined contribution basis, I have money left over. I can buy additional products, dental, vision, individual life insurance, or a disability, or I can use that money to pay my out-of-pocket costs so I don't have to go to the bank to borrow the money. What do you think needs to be done then to expand and strengthen the individual market?
In the House bill that recently came out of the House, we have in that legislation that allows for equal tax treatment for choice. It's called the Choice Plan, Individual Consumer Health Reimbursement Accounts as an insured product. Number one. Number two, secondly, there are rules that we need that allow employees to move into defined contribution and buy from the individual marketplace.
And those are in the bill. Now, the Senate has revised it. It will go through a number of revisions before it's ultimately passed. It has to go back to the House. So how it all pans out, we don't know. But it's in the middle of the discussion at this very important time. So where do you see the individual market being in the next 10 years? We think it could cover 120 million Americans. So all the people in the Affordable Care Act now,
Small group employers, middle market employers at 79 billion lives, gig workers 20 to 30 million lives. And then we even have large employers with thousands of employees who are looking at this as an opportunity to cover their part-time workers, but also employees who want to buy their own product. Oscar Health CEO Mark Bertolini, thank you so much for helping us understand this really important pillar of the insurance market. Thank you, Kathleen. Great being with you. Now I'll toss it back to The Washington Post.
Hello. For those of you just joining, I'm Paige Winfield Cunningham, a health policy reporter here at The Washington Post. And for our second segment, I'm pleased to be joined by Larry Levitt, Executive Vice President for Health Policy at KFF, a nonpartisan health policy organization, and Gene Lambrou, Director of Healthcare Reform and a Senior Fellow at the Century Foundation. Welcome to you both. Thank you. Thanks for having us.
Well, let's start with the buzziest topic at hand and something I'm sure you both are watching closely, this legislation that Republicans are trying to pass in Congress as we speak. And Larry, the CBO estimates that this one big, beautiful bill will result in about 12 million fewer Americans having health coverage
a decade from now, and I know you and I have already talked about this before, but I wonder if you could explain for our audience, what are the primary mechanisms that would be driving this coverage loss?
So the primary mechanism is a trillion dollars in cuts to federal spending on Medicaid and the Affordable Care Act. And, you know, those cuts take many different forms. A big driver of the loss of Medicaid coverage would be a new work requirement that would
mean upwards of 5 million more people would be uninsured. And that's not because they're not working. It's not because they wouldn't qualify for exemptions like being a parent or being ill or going to school. It's because they would fail to navigate bureaucratic requirements for reporting.
You mentioned work requirements. I actually want to ask you about that because I know that that's a big point of messaging for Republicans and actually something that pulls quite well in the bill compared to some of the other provisions. I wonder, Larry, if you could, I mean, why do you think that pulls well and why does that resonate with people?
Well, I think, you know, the idea of work certainly does resonate with people. Our polls do show that people like the idea of a work requirement in Medicaid. But interestingly, that support is quite soft if you give people arguments or facts about it.
about work requirements. So for example, the idea that it would lead to more people uninsured because they couldn't navigate the reporting requirements, support drops quite a bit. Yeah, certainly the idea that people should be working resonates with the public. But the truth is about two-thirds of adults on Medicaid who aren't disabled, who aren't seniors, are already working. So in some ways, it's a solution in search of a problem.
Well, and I know we've seen a couple of states try to implement work requirements. And I know in Arkansas, we saw significant coverage losses when they undertook those. Jean, I want to toss it to you. And we know that, as Larry noted, the bill would save a lot of money with these cuts. But what happens when people lose coverage but still have to seek care?
You know, we have decades worth of research that shows that when somebody doesn't have coverage, they'll skip care, they'll delay care. That often means that they find themselves going to an emergency room when they could have gotten treatment before them.
That is the most expensive form of care. It strains the hospitals, trains the healthcare system. And that's why so many of our hospitals in this country have expressed concern about what is an effectively 50% increase in the number of uninsured Americans under this bill.
The effects go beyond that, though. We know that people who don't have health care struggle to work. Their productivity is down. Children can't learn as well if they're uninsured. We see community-wide effects on our businesses, on our growth, our economic growth. So this is not just a health problem. It is an economic problem.
Well, and I know that there's a lot of talk about chronic disease and trying to make Americans fundamentally healthier. We see a lot of that out of HHS and RFK Jr. And Jean, I just would love your thoughts on, you know, if Republicans do pass this legislation, that that seems sort of at odds with the broad goal of making Americans healthier. What do you think?
Yeah, I have to say that going back to what Larry said earlier, this is a bill that has about $1.8 trillion worth of spending cuts in it. About a trillion of that is coming from health care with no investment back in the health care system.
Are there changes in here that, for example, go after the high prices of drugs or go after healthcare consolidation and complexity that are driving up healthcare costs? No, none of that is in here. I'll just do a contrast to back in the day when we were working in the Affordable Care Act.
We did save over a trillion dollars in healthcare spending as well as in healthcare taxes, but we reinvested about 900 billion of that back into the health coverage system. That meant that 32 million more people gained insurance, not 16 million people losing insurance, and we were able to do that and still reduce the deficit.
The Affordable Care Act actually lowered the national deficit in debt, while this bill would increase it by anywhere from $2.4 trillion to $2.8 trillion. So we do think that this is going in a direction that doesn't have much to do with health outcomes, but certainly will have broad impacts on the health system.
Larry, I'm sure you've seen the messaging from Republicans about this legislation. A lot of it centers around reducing waste, fraud and abuse. And I want to ask you first about the marketplaces, because we do know that there is marketplace fraud. I wrote about
that recently, especially through these brokers that are basically taking advantage of lax rules to get people enrolled. And I'm just wondering if you have a sense of how big of a problem that is and is that something that should be addressed, whether through legislation or through administrative action?
Yeah, I don't think you could find anyone who would say that we shouldn't address fraud in public programs, whether that's Medicaid or the Affordable Care Act. As you said, I mean, the evidence of fraud in the ACA marketplace, particularly the federal marketplace,
place is being perpetrated by brokers, brokers who are switching people's plans without their knowledge, signing them up without their knowledge. And no question, I think everyone would agree we should go after that. And there have been some steps taken dating back to the Biden administration and now continuing in the Trump administration to
address that. But these changes to the Affordable Care Act go well beyond fraud, waste, and abuse, both in Medicaid and the ACA. Many of the changes to the ACA would make lawfully present immigrants ineligible for coverage. You can agree or disagree with that on policy grounds, but it's
not abroad. These are people here lawfully and eligible for coverage. And new requirements that make people jump through hoops to verify their income isn't really directed at fraud. It would put paperwork burdens in front of people that would result in fewer people covered.
And I know Republicans are applying this messaging not just to the marketplace, but also to Medicaid, and they're alleging huge waste, fraud and abuse there. Jean, what do we know about fraud in Medicaid? You know, we certainly have government watchdog groups that look at this annually, inspectors general, the governmental accountability office. And I know policymakers take those very seriously. But when you go line by line through the bill,
You can find some provisions that look straight on about anti-fraud activity, like preventing duplicative enrollment and trying to make sure that people are not getting payments or not being made twice on behalf of one person. But when you rack up those savings, they only come up to about 3.5% of all the Medicaid spending in this bill. I think we have to be clear-eyed about what's going on here. This is reducing federal spending.
partly at the cost of people losing insurance, but also by shifting costs to states. And those states, and I just, I live in the state of Maine, I ran our Maine Medicaid program, there aren't that many places to turn. So those states would love to be able to find
Fraud savings to cut and they're on the front lines of doing that every single day actually more than the federal government, but that is just not going to solve for losing $800 billion of Medicaid spending from the federal government.
And, Jean, we've heard, of course, a huge outcry from hospitals about this legislation, particularly rural ones. And the Senate actually moved to crack down on their payments more harshly than the House version. And then just this morning, we have news that the Senate is considering adding an extra fund for rural hospitals into the legislation, I believe, to sort of respond to some concerns by Republicans that they're
cutting into funds for rural hospitals too much. But I mean, I don't know if you've had a chance to look at that. I think it's around 18 billion. But what's your sense of the effects on rural hospitals, assuming this legislation does eventually become law?
Yeah, look, we've been there before. You know, we had the provider relief fund most recently in the COVID-19 bills that in the state of Maine helped two of our hospitals go out of bankruptcy. We have a Medicaid dish program that's been around for decades. It provides some supplemental payments.
a pot of funding doesn't equal sustainable payments. We've seen that time and time again. And I would say when people talk about this not cutting Medicaid, as the speaker did yesterday, why would we need a relief fund that's going to be time-limited, temporary, and non-transparent if this weren't actually cutting Medicaid? So I am skeptical that it will deliver on the promises that are being made about it.
I know you two were around back in 2017 when Congress tried to repeal Obamacare, and we all saw how that played out. And I'm going to ask each of you to make your best guess right now for how the next week, this next week plays out. Do you think Congress is actually going to manage to pass this one big, beautiful bill? And Jean, you first.
Yeah, I am not a political prognosticator. I will say that this is happening very fast with very little time for people to understand what's going on, to get the kind of airing of the legislative language or what this means for various sectors.
I worry about how fast this is moving and worry that should it indeed move in the next week, there will be unintended consequences like we haven't seen before. As a reminder,
15 years ago, there was a lot of concern about how fast, quote unquote, fast the Affordable Care Act was moving through the process. Yet we have White House forums, public hearings, bipartisan amendments on the bill, time to look at the bill before there was any votes. None of that's happening right now. And I am quite concerned that should indeed this be rushed through in the next week, there will be
large-scale negative impacts of a bill that we already know is moving funding from people in the lowest decile of income to people in the highest. CBO estimates that the redistribution of wealth in this bill would be a cut for low-income people of about $1,600, and it would be an increase for the highest-income people of $12,000. Larry, what about you? Is it going to pass?
It's hard to predict the next hour these days, let alone the next week. But when we look at this debate compared to the 2018 Obamacare repeal debate, it has a lot of similarities. I mean, the scale of the cuts in terms of federal spending reductions, the scale of
scale reduction in the number of people with health insurance are, you know, on the order of what would have happened if the Affordable Care Act had been repealed in 2017. On the other hand, it is very different. That was a very focused health care debate that proved very controversial politically. This is a
very big, whether it's beautiful or not is in the eye of the beholder, but it's a very big bill that includes not just healthcare spending cuts, but also tax cuts. So it's a very different debate. Things like weakening preexisting condition protections, which were very controversial in 2017, are not part of the debate today. So I think, I'm not expecting the kind of
blowback that we saw or the thumbs down from Senator McCain at the end of the 2017 ACA repeal debate. So I am expecting this bill to go through, although in what form exactly, I'm not so sure. But I do think there will, once people realize what's in this bill and the magnitude of the federal spent
spending cuts on healthcare, that there will be a political blowback like we saw in 2017.
I want to ask you both about something else that was buzzy this week. At the beginning of the week, the major health insurers announced that they're going to ease up on prior authorization requirements. And as you know, this has long been considered a barrier for patients to get quick and efficient care. But we've also seen promises like this before from the health insurance industry. So, Larry, do you think insurers are going to follow through on these promises?
I have no doubt insurers will follow through at least for a while. But, you know, the history of voluntary industry efforts like this is that they're not necessarily sustainable when they're not backed up with government regulation and enforcement.
But, you know, we are in a period now where there is a lot of opposition to prior authorization by the insurance industry, maybe even some strange bedfellows with alliances between consumer advocates and the Make America Healthy Again movement and the Trump administration, which has a kind of anti-industry bent. So, you know, it's certainly movement in a positive direction for patients.
but I'm not sure it's sustainable without some kind of enforcement. And Jean, how big of a problem do you think prior authorization is right now? And what could be the impact on consumers from these changes the insurance industry is promising?
You know, we know it's a big issue because we just hear about it. It is on people's minds. In the same way people, you know, 20 years ago learned the term pre-existing conditions, which is a technical insurance term, because it affected them, people know the term prior authorization for exactly the same reason. It's just affecting an increasing number of people, making them jump through these hoops. I
I agree totally with Larry that this voluntary effort is a step in the right direction, but there'll need to be more
I would argue going back to something that is different from 2017 is we do have more people insured. We just hit the record high number of Americans or percent of Americans with health coverage, including people in private coverage. So they're very aware of this. And especially with the changes coming out of this legislation, these rules, they're going to be unhappy. So I do think that we'll see action soon.
no matter what on some of these issues, but more of these pocketbook issues. As a reminder, when we look at the ACA enrollment in the marketplaces these days, who are these people? They're middle income people, they're older people, they're rural residents where there's not a lot of job-based coverage. And those people are going to be quite focused on the congressional debate given what's going on currently in this bill. And I do think when
people are trying to then figure out what's next. We're going to see this marrying how do we improve private coverage, the quality of it, the access to it, while we expand it. I think those two come hand in hand, along with trying to get at that age-old problem, yes, the prices. Well, I want to end on a hopeful note. I'd like to ask each of you, what is one policy idea that is both feasible and would improve healthcare in America? Larry, you go first.
I don't know, feasible is hard. It's very hard to change the healthcare system. But
You know, I do think the one positive thing we've seen from the new administration, from Secretary Kennedy, is a focus on chronic disease. You know, I think we do need to take efforts to make people healthier. What's missing from that effort is any focus on coverage or affordability. But focusing on people's health is important. Jean, what would you leave us with?
I would go to, you know, can we harness AI in a way that's positive for people? You know, we have an extremely complicated healthcare system. There's a lot of paperwork. There's a lot of bureaucracy in it. And to the extent that we can figure out ways to take out the
boring, inefficient, error-ridden parts of our healthcare system. I think that's a positive. That was some of the original promise of what the administration came in to do with Doge and other elements of it. I'm hopeful that that
promise could be met with real policy action and partnership with the private health care sector, public health care sector, and states to really try to figure out a way to truly get at some of the overly complex and administratively costly parts of our health care system. Well, unfortunately, we're out of time, so we'll have to leave it there. But this has been an illuminating conversation. Larry, Jean, thank you so much for joining us today. Thanks, Paige.
Thanks for listening. For more conversations like these, follow our Washington Post Live podcast page on Spotify and stay tuned every Friday for our weekly episodes. I'm Paige Winfield Cunningham. Thanks for listening.
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