Discussion on Medicaid & Medicare Reform : CSPAN2 : June 4, 2024 10:14pm-11:47pm EDT : Free Borrow & Streaming : Internet Archive (2024)

that was the last time he votes in this house after 59 years. a great servant ■/

>> good morning. for our event this and the health policy scholar so you're talking about today medicaid and medicare coverage lower healthcare costs and

quality. so this is a version of let's make a deal. and with the health policy but the let's make a deal concept that the early canadian-american and pioneers but we are combining let's make a deal let's make a really new deal and it's a different approach to the entitlements and projects.

basically we had a lineup of wacky customs and dis today and then you are chosen for the show so the idea is and or 3. the idea you could take a risk and come out better than that we are talking about with today's program and takes a few more risks with what you do if you could do better now the problem if you did bad it was a song.

so with tay's program i will introduce in just a moment. with a provocative papers and 1 of the most frequently and then to push the envelope. and then moving toward another policies so what we have you don't have to read through but d expansion. and with the affordable high quality health care.

same title and asset we are trying to do. and then to leverage them. also going on boo called approach talk about the band of highly skilled operativescore with corporate evildoers and with and leveraging with the medicare financial disaster■c bt

what could they do differently about medicare? and talk about the financial off healthcare coverage this is the building blocks but at the core of what is being proposed this is a concept going back de economics with the inflatiory but you are the customer to have more leverage and conol cash transactions and more transparent■t and also the qualy

produced and with the educated consumer. that is a stripped-down version but nevertheless that had value at the time. and then ultimately they have to close up shop in with the other retail sectors. so to think of with the welfare program that is pretty much with the healthcare system but this puts it into the system so they are not aslong hungry to cut ban

their appetite. so with the overall value so he produces a lot of work and scholar at a he i and more of a full-time job among any -- -- among many others at georgetown published a number of books before■t but overcharged a few years ago talk about to some extent. and then when he was special

counsel. and trying to put a normal brain into the system. like a frankenstein moment. work explaining how this could work. ou all for coming. and i think i can this is a paper with charlie silver from the university of texas and the title i gave him harkens back■x

these articles started as 1 and thinking about the problem of how we might make mediid appealt had not opted in by crafting a program differently and then subsequently and realized they promised for a medicareorm then traditionally was the case so we have these 2 articles with footnotes but i am happy to share them with anybody the audience who is interested and

then to lower the expectations this is to grade a long time policy analyst working in washington on the side of the divide over a prior article 2007 but surprisin the law professors were right accordingly you may want to lower your expectations about this idea the history of health reform with those ideas sometimes they get deployed or

ignored this is actually the graphic aei sent out but you did not choose it. it's a very important issue with lots of government policies. and where the aspects of the current healthcare system. and with the c- grade with the performance of the system that's not to say and it is truly exceptional with most of the career spent studying the healthcare system i got to see it on the other side is a trauma patient and is pretty exceptional let's not talk about

the building that followed but assume that are not hiccups or problems or difficulties we have not thought about. unintended consequences. by way of analogy there is a movie a couple years ago called particle fev a a wonderful quote from a theoretical physicist jumping from failure to failure there is a lot of that in health policy as well. and then to focus on the things that have gone wrong but there is nsh things the big 3 issues of health policy i used to tell my students

be a health policy analyst as well but i stopped doing that because they did not like that but nonetheless it is a useful framework and the cost and benefits of any proposed reform of what i will be talking about today or whatever the latest is whatever that policy shop the american healthcare system it doesn't matter where you look. the perennial and the only

thing that changes is how long it would be. it goes up or down and then we see the cherry blossoms they go away but we don't do much of anything unless the date for the expiration of the trust fund and then we see some tweaks but as pointed out to spend money on other things. the bigger problem it was the fundamental fiscal imbalance more than any possible tax revenue. with the promises that we made.

but is not nearly as accessible the trust fund was going bankrupt with the huge liability. and from this from the "washington post" and at every stage to say the data shows that you will be okay during the segment but it cannot go on indefinitely than there is a reckoning. the only question when and if we will be around for■x this medicare is -- -- has real challenges like overcharge the

unfortunate reality is a low-quality pair to create systematic incentives it is a massive payer of bills they might argue about the price not price negotiator years old there is evidence the more medicare spends less the quality of the care that is delivered is not typically th working and efficiency is the trump card not intended for why we should do medicare for all

basically has a 1 or 2 percent overhead favorably to the private insurance market the difficulty is to explain this the formula by which efficiency is fundamentally flawed. and the difficulty the more money you waste and the right way to do the calculation and subtract to the numerator from the denominator if you do it that way i will not bore you with the math but staggeringly high numbers and then to be significantly higher.

the true cost of delivering high-quality so the pitcher it is a more efficient program and for the private insurers and you shouldn't assume it i uniquely efficient soo medicait started thinking about the problems the 10 states that decided not to expand medicaid in response with the affordable care act that it was coercive

and gave states the option pretty much immediately half of the states opted in and this is year-by-year■■ and with the medicaid expansion'sorame page prior to the aff■dordable care t including the series of core populations every state had. and there are huge variations state to state to broaden the populations that would be covered raising the income limits and the practical significance of that and that they suddenly qualify for medicaid.

and those that result in access problems.■) half of the states opted and immediately and starting in■ and then for expansion for those days that opted in those that have not done so in the far right column and those that chose to opt in that yearo hight small states but with the sizable population and the results is we started this project if they could be

persuaded to opt in and that 1 generally things that health policy with those empirical studies that should make you cautious about drawing a conclusion in any event the geography for the holdout sta you can see right but in the healt circles but they are racist because they are part of the confederacy some things that complicate that those that were never part of the confederacy some more.

and there are other factors to consider like the fiscal challenges of the individual states are facing. that makes them reluctant to sign on to heavily and opting into the traditional medicaid program. and what was alluded to earlier the idea behind this is let's think about ways we can revise the offer other than do it our way and we will subsidize sometimes 90 percent depending

on the budgetary dynamics but the core idea is rather than saying do what our way the proposal medicaid offer the state something that would be mo address the fiscal challenges in the idea essentially moving from the defined benefit approach where the state could set the amount of money they wish to spend in the federal government would match that and it's the funding side of that it's the production healthcare side rather than waiting for bills and checks with the artificially low

instead we would find hsa or the beneficiaries by buying catastrophic coverage and spending on the social determinants of health so that isonsistent with first of all how we handle social security and the child tax credit and those accounts in the private market the core idea is to give medicare and medicaid beneficiaries money instead of paying the providers we ship that money into hsa with a direct purchasing market and direct purchasing creates huge incentives for providers so the

broad losses and it will take keep spending our own money and spending on things that they value. and then for the state government to provide housing and then food stamps and vouchers then they should spend it as they see fit and the medicaid version this is something similar direct purchasing with physical

therapist and hospitalanything . that has been the traditional approach but what we are seeing in the healthcare financing system over time with medicaid has of the 1115 waiver is to allow the state start spending money on the social determinants of health for medicaid though so this is no different it just cuts out the middleman leading the beneficiary make their own decisionse things that drive people crazy about the current system are no longer necessary so the government will not be the business ofes are well known for its too high you overpay if it's too high you don't have access there isn't

much need for prior approval requirements the administrative headaches because they deal direct with their the federal or state government will have to have up front pricing in the traditional contract principles people are bound by what they are offering with price has done a lot of work and we would be happy to wax poetic about the challenges becomes much more automatic we don't mandate price transparency from the retail market but apart from

that it results because the buyers are trying to sell things that was in the interest congress finally gets control of the budget for medicare medicaid in the state legislatures have control to set the maximum amount rather than being on they actually benefit from the lower prices on prior slide basically builds on development with the child with a dramatic move over the last several decades and toward the defined

contribution.■ with trillion dollars in medicare and we are getting there. but there is no shortage but they try to get more than they are entitled to ascent lack of precedent in this could be in line with social security and then to figure out how much for beniciary into the savings account and to what extent and

reasonable people can disagree about the right formula of concern if you give them money they will use it and ways for those that are risk averse will not like and they spend it with unnecessary services spent on social determinants of health and we need to think hard about what we should do and how we handle that i'm happy talk about it with q&a this is not everything will work out fine we have to be tough-minded the way it is susceptible.

the immediate response of providers is to highlight the way they come out the losers but that's an indication not doing a very good job is because they do the federal or state but in ne think about do we subsidize and the community health centers rural locations all of these i'm sure you will hear about thinking with never heard about this and it will be a disaster. we have thought about that but this is a better strategy and we should make adjustments rather than using the medicare or

medicaid program. >> aid to patients with dependent providers. >> the last point i want to leave you with perfect no human institution is and 1 is the 3 little pigs want to privatize health care. and to say let's compromise and that is the nobody has the outcome they wan with that proposal we are making but how it compares the highly reality we find ourselves in but with a

quote from the article shortly after the affordable care act was implemented with the distortion and consequences were being realized by those who thought it was a idea. of course we want people to healthcare just didn't realize i would pay for it. some of them they have to pay for personally. and the sooner we decide how much we want to spend on t the better off we will be. i think i am well within my time so i reserve my time. >> and the customers that you

could give cash which is just as good as money currently senior policy fellow and a lot of work to interact with national policy as well and has round and what do they try to do what can't they do? additional background as a senior advisor to the administrator of cfs to work with all sorts of proposals when insurance regulationre the conce innovative but there could be other opportunities there first how tohae

individual markets and now peter nelson. >> thank you so much. >> i don't really practice law. in the previous administration i got out of the hotel showing with my uber today and that is the humphrey building where hhs is headquartered so here am to i have a lot of alignment in fact i have been talking about the benefits of defined contribution

for years pretty much since i started go back to the first major report ever wrotein the ra primer how employer-based benefits and the tax code distort the healthcare market employers generally offer a health plan and then undermines plans the actual consumers want and need and since i wrote that pursuing policies to give individuals more control of the health plans that theyhoose that's a better way to organize theto drive more competition i also

have a lot of alignment and the need for a deal i have some experience what it might take to strike a deal because i was in the previous administration i started late 2017 and at the time they were under tremendous pressure to expand medicaid. it outlined all the spaces thatt 1 of the reason i have a lot of pressure is because thenitiate m they knew they would extend dramatic -- -- medicaid and how they expanded medicaid of course to have a huge impact on the state budgets and in particular

1 state has an issue they knew the pallet was coming■■f so we wanted to come up with some sort of idea that is an alternative to expand medicaid that stirred up debate and in july 2018 trump spurns the proposal after the debate. i wasn't in the room during that debate and then seeing how furious it was becauseas a prode

want to expand with the federal population and those that were more conservative encouraging at view 90 percent match that still keep cost going out of control and so basically the white house was concerned about thatmuch ind ultimately at the time it was damned if you do are damned if you don't position. and those that critics expand te

have very expansion recently but that doesn't mean the issue gone we still have the system that expanded medicaid mostly so with that in our conversations for extending medicaid for georgia and mississippi and with these holdout states ultimately they will expand medicaid so we really do need to come up with a better approach so what if medicaid expansion has another opportuny?

i think the answer is yes time is a big obstacle getting to with medicaid expansion needed time these are waivers for the affordable care act to let them get out from certain other provisions. we published guidance in 2018 that allows far more flexibility however we knew we were still late in the game. by fall 2018 the legislative session had already been organized and then it is 2020 and states would not take that on and that is as when they coul■9d approach and

the medicaid situation under the same sort of timeline assuming you have chis far moreo so what does it look like the dd contribution plan to be above 100 percent and that would be coordinated with the leader possibly but what could that look like could that be a defined contribution plan? i don't have the waivers getting approved because it

doesn't have the same automatic benefit structure but just let's assume that maybe congress would step in to say it is okay but with the policy issueshat need to be addressed if we go down the road the main problem with the defined contribution approach what needs addressed is the fact that the population of people who were 100 percent have higher health risk with a higher rate of chemical dependency a higher rate of mental health issues. the first problem relates to the risk as a defined contribution of the individual of the insuranceaé mdefined contributie used for coverage and then moves into the individual market it

will■p increase the risk profile of the individual market and the second issue these people with higher cost conditions less ability to manage their care and then basically result and could increase cost to the state and then they just delay their care more. so let's take a deeper dive and we have some examples to think about because there were medicaid expansion and then to provide coverage to the expansion population arkansas has done this and with the new

hampshire approach then ending in 2018 and when they ended 2018 they se secretary to explain why they stopped and basically said that by stopping it it will bring greater stability to the marketplace which experienced re inclusion of those receiving medicaid services this gives a picture of what was going on in new hampshire that enrollment popped up in 2016. . .

you. ally, it's a similar way to say the same story. but it uses a little different measure, the hierarchical condition categories and it shows that when you look at the new hampshire market and i also included the arkansas market because they also were putting the medicaid population into tha individual market. there is a much higher percent of people with one or more chronic conditions in those

markets when you look at 2018 in both markets and you still have higher percentage in new hampshire and two plus conditions.and 3 plus then 2019 in new hampshire basically drops medicaid peoplee now all of a sudden below national average. the national average is the dotted line. so there's a very clear impact when you start introducing this population to the individual market and it's not a and so whe looking at what we think you need to do to create a defined contribution approach, you definite n to account for that with some mechanism. i was introduced to this issue back in 2019.

and what happened is basically we create -- the state of minnesota to develop, okay, how can we do this better before. we were just a financing mechanism for hospitals but really wasn't serving the patients very well. and what we ended up with was a much better approach that actually created incentives for the local hospitals in the twin cities to take a much more managed approach to the patient and identifying patient needs on the front end versus waiting for people to go into the emergency department. and -- and that worked immediately but then medicaid expansion happened. hmo, what they do is they are very much coordinated with federally qualified health centers, the level one trauma

hospital and county social services department. they are very coordinated. they've had a lot of success in what they've been doing and i think there is a sll of people who really need something like this within this approach but that is not the entire population of people. what new hampshire and arkansas found was that when people were moved into individual market coverage, they had much better outcomes, you actually get to see a specialist way quick medi. evaluation reports for those programs were very good, the trouble is that in new hampshire it really had negative impact on the individual market and they had to move on. those are the two things you close attention to

with this defined contribution approach w. that, i will leave it to the next speaker. he has extensive experience focusing on medicaid congress staffer, executive branch outside scholar, working on -- you think of henry waxman has hands all over the building with the medicaid program a lot of that legislation is work with them. more rectly working with medicaid managed care organizations for children research on that and another lawyer to talk about little different perspective, andy schneider.

>> good morning. thank you, tom inviting me. i'm going to be brief, i want oh to just spend a minute explaining to you that the center for children andamilie where i work is nonpartisan policy and research center at the public policy at georgetown university and -- >> i'm sorry. >> yeah. >> you're talking somebody that >> there we go. all of the information that everybody needs. >> that's good, okay.

our mission is basically that children in the families have affordable high-quality healthcare coverage and that means mostlile making sure that ifow-income families are eligible for medicaid or chip, the child health insurance program they are enrolled and that the programs work. so you can see where this is going, sort of defined benefit guy. defined contribution guy so we have an issue here. what i do like about paper and i will talk about medicaid expansion issue is that it recognizes there is a probl havt states, they have been holding out for while and they're leaving a lot of people dangling in the wind uninsured. so we do need to solve for that and i appreciate the deficit of

the paper and the commentator to figure out ways to make improve the situation in those states. i don't think the proposed solution is going to work. i will use tom's metaphor. i think we are going to end up if we go down this road but let's talk about that for a second. so first of all, the population here are low-income adults and by low-income we are talking under $21,000 a year in income. okay. and many of them have -- particularly in ten states where parents with feint children, caretaker relatives, the median income eligibility levels for medicaid now are below half of

the poverty level so under $7,500 for an individl, so we are talking about very poor people and asíe -- as peter mentioned, higher mental health problems, mental health conditions and substances population, so, and, of course, a lot of them have been uninsured for a lg time on the needs for health care and highek they start withhat you saw of the decline in the holdout states from 2015 to 2023 and we are moving to ten remaining states and the -- one of the drivers there as alluded to here is that i

notion of a initiative where people decide to go to the ballot and vote whether they want healthcare coverage or not and turns out that the number of the states 7 in fact, that have gone into medicaid expansion, idaho, maine, missouri, nebraska, oklahoma, south carolina, utah and all those state with ballot initiatives, voted for healthcare coverage of the variety. and it's not entirely surt way does the deal on the table is not a bad deal. if you're not into defining benefits, yes, it's not a great deal but if you'reon the notiont the federal government will pay 90% on an open-ended basis of the cost of coverage for your

expansion population, you have have defined benefit package for the population, but if you t the deal now and you have haven't expanded yet, you get an additional 5 for the entire than expansion for two years it's a very good deal, and north carolina is, you know, a state where i think most people would agree that it made that's in place, there are, of course, questions being raised ab the 90% match is going away and nothing is going expansion have projected it and nobody has walked

and i know in the paper there is reasonable concern of low-tax states want to go stay low tax. if you're allow-tax state, you don't take this up event though the federal government is sayins some residual liability for you, state policy maker. so if you look at the lowest, ten states with the lowest tax burden which i think to think the paper authors for introducing me to this reading system, total tax burden. six of them new hampshire, delaware, south carolina, north carolina, oklahoma are all expansion states, some of them by valid initiative and some of them just came in right up front like new hampshire and delaware and nth states

have walked away, they are low tax, very low tax. you do have to ask a question and i'm not an expert, how bad exactly is this deal for low-tax states, the position to protect the low tax status and still reduce the number of uninsured in the state protect emic health centers, share safety net institutions and federally qualified health centers, et cetera, it's just a question. just a question. so the -- as you can guess i'm incrementalist about this area generally. i do, i do think it's worth proposal on the table.t the i had some questions about it and then i will stop. so there's a reference in the proposal to overall cap on

spending, so i didn't know how to read that and i hope this comes out in the discussion but if you're talking about a federal attack on federal contributions in the matching form to state spending on this population and these states, i think that the concerns for some of us who like the current structure of the programt it cae improved, there's lots of things wrong with it and it needs to be improved but one step at a time, please. so what is that overall cap on spending and do thetes who we are looking to market this proposal too understand that there would be an overall cap on federal spending for them. and if there is, what are t implications for the people,

great deal of respect for the ability of the market for for inflation,

the idea of how do we get there proposal anywhere, congress seems to be unlikely for the reasons that you can understand right now, the -- if the state is going to pursuewould be and n about how this all works, it would be through the waiver process and we have a statutory standard which is likely to -- is the demonstration likely to

assist in promoting the objectives of the medicaid program and the medicate program, you know, is a defined medicaid program. and future it will be, so there's a serious question as to whether adopting a contribution model is most of the benefit program. particularly given the risk of shifting across the healthcare inflation to the states to the5á beneficiaries and without any clear indication that it's going to make any change in prizing behavior for people with strong monopolistic positions. i appreciate in solving the coverage gap or remaining■& --

thank you. feeling like matt damon is the last guest on the show, but whatever, we will squeeze before we get to q&a and this is continuing on, david tried to lower some expectations, i can lower them even further. it's not that hard. think of this as friendly stress testing for the way in which is somewhat at war between what might be advantageous marketing and then the complications of administration and they're not often at war with each other in this area. now we could say the art, the health policy deal but i mean the usual way of doing the art of the deal. we are going to move beyond that although there's parallels with that in terms of how you can do

that so i think and again, i think now the price is rht on this one as brought down from what it

originally was. i tried to check on amazon today but even resale markets are working well on that front in terms of having demand match supply. how about some slogans? you can use some help on this front, i think. i offered a few here. some of them need to go back to focus group, perhaps, you are talking to the customer, get more for less, that's the standard republican, tomorrow is your problem not mine. you need to find allies, that's the other components. new technology, new face on the product.

telecommunications, information technology, some of the peoe wanted stuff that they didn't know they wanted before and didn't know it was available to them. maybe do so in transportation energy and that's the area where we have deregulation and the importance to have new winners than new losers you can count uy more to do this. front-row gain, promises of back-end payments but they don't necessarily arrive. that's the marketing deal. also previous work. you to have the right enemies, you have to have allies but enemies. the condition that i noticed in government called bureaucrats, birthday effect, acquired on thd it. they don't have a treatment for it. companies are working on that, maybe the cash free cosmetic cash-base cosmetic surgery will do that. special interest, providers, great and envy.

enemies but also can be your allies, a mix and match depending on the side that you're looking for. personal responsibility, gratification, that's pretty uphill, those are your enemies on this front if you're talking about managing your own system, of course, the systems is doing it as well. now, you have to have very simple solutions, of course, i usually caution others front, words of wisdom for every complex problem there's an answer that is clear, simple and wrong which can happen on occasion public policy and that is a first-party consumers can solve all, maybe they can solve. the last rule is to never give

up and never surrender a to thas key players in do it better. they are exactly the folks you're trying not to get around and there's problem of benefits. i'm running quickly but i can always go faster than that. there are problems in terms of the nitty-gritty in terms of why, why not and how. how is the big problem. let's talk about why you would want to do this. we have to get published. that's numberthere are other on. let's move from that. desperation, no other ways out, getting in the way of higher objectives, you move my cheese and i want et to be used for something and so that's the real healthcare spending and use it for something else you will have difficulty. identifiable winners that you can come up getting in the way of higher objectives, temporary

suspension of disbelief will work pretty well. we have newly appealing benefits, dress up the folks that you're going to aid and pay appealing and charming, you will get that going forward. why not, it's health policy disruption, inertia is the most powerful force, more visible losers are usually the case when you make any type of changes and the windows of harm ontic convergence for legislating or major undertakings are fairly rare because our system is bias to oppose delay, just delay things are wired, they a to change on that front. and disturbed mental resting places we have. we like to think that we gave it the office, we don't have to look under the hood. we felt like we did that well enough and that kind of took

care of it. we are taking care -- a little bit of that distrust of lettingi beneficiaries have their own money to handle when are not sure to be done. we like to pretend that we have taken care of the problem even if we haven't. all right. i'm going to cut through my culture, thespontaneous combusr one which is how you can be a millionaire and not pay taxes as steven martin million dollars, second tell the irs i forgot when they ask you to pay the taxes or help savings account which would let you be a millionaire and you could not pay taxes on it but that's another approach to it. that's how it really matters, know, we already got medicare advantage, we've got medicaid managed care, that's close enough for us in terms of

private, without get this vigorous marketplace. the problem is before dealing with averages and throwing the money out as opposed to adjusting matching risk and reward, some are going to come up. if you reall give it to those in need, why didn't i get mind and imperative always feeds the middle-class first in health care. trust is a big problem. who do you trust to handle the health care, you don't trust the insurers, you don't trust the government, actually they do trust employers in latest polling but the problem is they don't trust ourselves and until making more decisions that's the problem where the default put option is where they are going to manage and handle. long-standing issue. i'm going to -- well, i have a couple more to go, what the heck. some other issues in terms of how to start which is what i had said, and talked about that

incrementally. not only incremental, you want to start small but the problem is if you start real smart it's too small so there's the sweet spot where it's large enough to have critical mass and you can't with hsa right from the start but not so small it just goes away and you can open doors but you can't push people through them. that's what you run into complications. the transitions opening slide david had in terms of the transition of social security and medicare, it's also true of any major health policy change, the early going is great when transition hits you and then the real tea, conflict between other goods versus subsidized medicine, when the they comes we want something else as opposed to increment of medicine, we will be there. i'm going to give david a few minutes to rebut the entire panel. i think that's the easiest wayo.

we will take questions from the audience. >> yeah, first, i want to thank tom peter and andy for their helpful comments and tomor going first and last with two bites at the apple and reminding one of the perils oriting things sometimes people find earlier papers, well, how do you what you said before. the title of the paper that he's alluding to is fixing injustices in health care and then send a guide for the perplexed or something like that. getting the haves to come out behind i think was the other part of the title. so these are issues that i've■■n been puzzling about in various ways for good long while. that was actually a response a paper, barack richmond who is now here in gw for those of you

who want to learn more about that, for peter's comments i, you know, i take your points about both the promise and the peril of doing sort of thing, i'm not sure because we are not calling for either a premium support o dumping, dumping sound -- adding people to market, the lessons from that carry-over quite so directly to this. the proposal is to give people money and let them spend it rather than giving them insurance and, you know, the political economy is giving them insurance, partly, i think, there's good research indicating medicaid beneficiaries don't6m value the coverage they receive anywhere near hundred cents on the dollar. it's a lot closer to 50 or 40 cents on the dollar and that pos for making people better off by

giving them something they value, money, rather than something they don't at full andy started off by saying i'm a defined benefit guy so my prospects for persuading them were low to begin with, right, i'd sell short that possibility and it's quite clear he doesn't think it'll work and that's fine, the laboratories of democracy ideas that individual states get to experiment with these things and that's true both of the states that opted into the current program and the stes that opted out of the expansion but what we are trying to do is meet them on their own terms rather than lecture them and they should take it. factors that we think are important. now, we don't know for sure what they will think as important.

so i don't view that, i don't take the view that it's 20 and now a 10. the trend will continue indefinitely. >> and it's not simply spite but it's politics, it's finances, it's the i didn't know i was going to be the one to pay for other care that may vary among states as to how much that's an impediment to moving forward.

as for, your know, 1332, and whether the courts will accept or not, i don't know. i think we will see. i don't think -- i think the goal of to provide access to health care for poor people. i don't think it was to run a defined benefit program. i think that's a means ratherq end. i only taught administrative law once. it was unpleasant experiment for my students and any time you teach something for the first time, i mentioned the trauma episode earlier and happened 3 weeks before the end of the semester, one of my students sent me an e-mail, said professor, i know t hate chevron but this seems a tad as a way to getting out of teaching it because they didn't have teach the last 3 weeks of the semester which was chevron.

but nonetheless, i think we won't know until we try it. that's true of all sorts of things but i think the imperfections of the■) current system particularly for medicaid beneficiaries who even in the states where they have expanded coverage that basically only works at hospital and in patients that didn't really givm which after all was a big part of the goal of the great society programs with open the doors to the health care system for people and i could go on but i won't, so thank you very much to all of the commentators and i look forward to comments from the audience and thank you for coming to hear about medicare and medicaid and define contribution approaches. >> now it's your turn.

>> identify yourself. to prepare your op-ed. an hour just a question would suffice. >> i'm gerald chandler, i have a question two-part question of medicate expansion. first system, system medicaid recipients to the how much health care are they getting compared to what they should get and the second part of the question is at the defined level. >> so on the first question there's been multiple studies about access of medicaidy well h pregnant moms. we do okay but not great with

kids. i think if you need a specialist you're facing some challenges, we sort of heard discussion of that already. and, you know, we can go through populations and diseases but certainly if you offer people the choice between being covered by medicare and medicaid it would be irrational to pick medicaid for regular health care sing homes are not covered by medicare so that would be the one might prefer medicaid. in terms of what is the right neither does anybody else but i would use what we are spending now as a starting point and see what the state's willingness to fund these things are and whether the federal government is willing to sortf continue its open-ended commitment when there are lots of half of the medicare budget,

medicare entirely. i think those are involve not just sort of, you know, positive issues of facts but also values and i know i'm no good at the■ó ladder. >> okay. >> just quickly on that, we have a lot of disagreements here. but i don't think anybody is going to disagree and i will just say that if you're allow-income adult and you're not eligible for traditional medicaid and you're in an expansion state, you're better off. you're better off than if you're uninsured. more likely to have access and s

general proposition and point two you have to look before you were making categorical statement about this in medicaid at each state because the way states administer the programs and the way things workgñ in the trenches in the different state delivery systems, there's a huge variation and, you know, the story in minnesota is different than the story in dc or the story in -- pick another california, it's just, before you go and answer that question, you to look at so how are things going in any particular state for that population. andy mentioned previously of new

hampshire and delaware doing better even though they are low-taxed states. they are doing better because they are lower taxed states. i like to a scattered plot of poverty rate versus the medi, the quality of access, the medicaid program because i think the lower the poverty rate the better your medicate program is going to be. it's really hard for them to make decision because that will put enormous pressure on the rest of the medicaid program because they have a lot more poor people than minnesota delaware and new hampshire and i think that's a big thing. we always need to recognize it's not racism in these states, it's resources. but any further questions and

seeing none, i will expand -- >> let me follow briefly. when i started working in this field, one of the first things people said about medicaid, if you've seen one medicaid program you've seen one medicaid program. there's obviously huge variation and that's going to complicate any response to how the medicaid program is doing and places pressure on getting good data but i think the other point about the research of medicaid versus being on ensured is the randomized study done in oregon gives us different results than observational studies that have been done and happy to talk more at length about that but's quitd reduces distress to see the healthcare system but the evidence on posite health effects has been much more the first year much lesss tha

aggressive in the sec year and then we didn't follow it unfortunately long enough to see whether there are morality effects, so, you know, i think the observational studies are much more positive, huge beneficial impacts but, you know, i do causal inference and stuff, trust randomized studies. >> part of the policemen ins ise wednesday to pay them for trying, not for necessarily succeeding so as long as you throw some services at well, we did our best. produce introduce yourself. >> trish mcdermott, your slides about the assumption that people will end up, the people

generally do a good job of evaluating cost and quality and making good decisions and that they would in this context and there by lower cost and increase care i have to wonder whether you really believe that and then the other is what happens lik somebody who is serious medical condition has spent all their money? >> yeah. on the former, you know, is peoe make decisions and maximize their own utility, i'm sorry? [away from microphone] >> well, if you look at behavior in the real world you see that except to extent there are a variety of impediments to doing it and that's an invitation for us to address those imped meant, a person that can sort it out for us. i've done work on i

evaluations of doctors. that's going to be a problem, right, but we do seem to have sorted it out in all sorts of negative markets elsewhere. and wh take steps to address it rather than running the entire world on a defined benefit model with all of the pathologies and he didn't like that word but i think it's half description and started in medicine and description of certain aspects or health care financing and delivery system. in terms of how do we deal with the unfortunate cases, well, i only have two minutes, right. not even that. no, that wouldottom's approach to this problem. my approach is to figure out

which one of those we think we want to fix and are willing to pay to fix. >> priorities. >> i think we set priorities. we also because this is a multiyear thing can recoup in second, third and money that was not available in the first years about how to handle that particular, this is not let them start proposal. this is an attempt to try to move from where we are to somewhere that has features that will be better. >> we are going wrap up in a couple of minutes. david is alluding to the■ of catastrophes, catastrophic insurance and then somehow the money does run out and the question is where the doughnut hole hidden or made more transparent but you can't pay for everything everywhere all of the time and who gets to

manage along the way. i said at the start of todayogro try to work through issues. it's hard to do this type of stuff, but t possibility that that one gleaming thought might come through and i said before starting preview, i seen pig's fly at least once and there's a possibility they'll do it again. so thank you all for coming today and please thank our speakers. [applause]

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